Maternal and Child Health

This article is by Dara Jackson-Garrett, a program associate at the Council on Foreign Relations. It has been nearly two years since Sierra Leone reported its first death caused by Ebola. The outbreak quickly accelerated across the country, ultimately killing 4,000 people and disrupting the country’s already fragile infrastructure. During the outbreak, Sierra Leone experienced a dramatic rise in the number of teen pregnancies, in large part due to a surge in sexual violence. The increase in sexual violence was partly caused by mandatory quarantines in temporary shelters, where girls were confined in close quarters with strangers and sometimes alone—without family or friends—leaving them vulnerable to abuse. In some parts of the country, the number of teen pregnancies increased by sixty-five percent. Yet in March 2015, the Sierra Leonean Minister of Education announced that visibly pregnant girls would not be allowed in schools, nor would they be allowed to take the Basic Education Certificate Examination when schools opened after a nine-month closure—policies that official figures suggested would keep three thousand girls out of school in a country where just 52 percent of adolescent girls are literate. When schools reopened, girls reported having to undergo humiliating pregnancy tests by having their breasts and stomachs inspected by teachers and nurses in front of other students. The justifications for the ban on visibly pregnant girls relied on stigmatizing attitudes and lacked consideration of the factors that drive pregnancy rates among adolescents in Sierra Leone. The Minister of Social Welfare, Gender and Children’s Affairs suggested that the school ban was an appropriate punishment for girls, telling Amnesty International, “During the Ebola outbreak children were given clear instructions: do not touch...These girls could not even comply with basic rules and there must be consequences for their actions.” However, teen pregnancy is linked to a lack of access to schooling, sexual education, or family planning services; in some cases, particularly during the epidemic, girls become pregnant after rape. The nine month school closure in Sierra Leone, combined with curfews and quarantines, increased girls’ risk of sexual violence. Most of the six-hundred-and-seventeen girls interviewed by Save the Children spoke about rape in their communities, noting the prevalence of attacks on girls in quarantine. People were quarantined with strangers, not just their families or close community members, leaving girls vulnerable in close quarters. In addition, girls who lost their parents or caregivers faced particularly high risks of sexual abuse and exploitation when trying to find shelter, food, or other basic needs. Children in Sierra Leone told Save the Children that some girls were forced into transactional sex to survive. Even before the epidemic, teenage pregnancy, child marriage, and sexual and gender-based violence (SGBV) were highly prevalent. In 2010, sixty-nine percent of Sierra Leonean women gave birth to their first child before turning eighteen. And in 2013, twenty-eight percent of girls ages fifteen to nineteen were pregnant or had a child. Child marriage was common throughout the country, with forty-four percent of women married by age eighteen in 2015, and eighteen percent married by age fifteen. In Sierra Leone, as in countries around the world, child marriage means that girls become pregnant at young ages, end their formal education early, and are more likely than unmarried peers to experience domestic violence. More than six thousand cases of sexual and gender-based violence were reported in Sierra Leone in the first eight months of 2013; the Ebola outbreak began a few months later, disrupting the little infrastructure in place for victims. The Ebola outbreak in Sierra Leone is a case study in how crises disproportionately affect women and girls. Outbreaks of infectious diseases can lead to a breakdown of a country’s infrastructure in a way that is very similar to violent conflict—businesses close, bringing the job market to a standstill; a country’s ability to import food can be severely weakened, leading to food shortages; and many countries’ weak education and health infrastructure all but collapses—with damaging effects for women and girls. In Sierra Leone, women’s ability to work and their wages have yet to recover, in large part because they worked in the sectors hit hardest by the outbreak, including health services and teaching. Weakened or destroyed social and economic infrastructure, notably rule of law, are correlated with an increase in sexual and gender-based violence. New reports suggest that the Ebola outbreak reduced maternal health care in Sierra Leone “to ruins.” And a team at the World Bank conducting a post-Ebola needs assessment of the education system found that considerable investment is needed to rebound from educational losses caused by the epidemic. The connection between women and girls’ empowerment and community resilience to crisis is well documented. When a country educates women and girls, it not only benefits them but also their communities: investments in girls’ education lead to women having better jobs and earning more money, increased economic growth, reduced infant and maternal mortality rates, increased life expectancy, decreased teenage pregnancy and child marriage, and reduced poverty. Thus the failure to provide adequate protections against sexual violence and the ban on pregnant girls from mainstream school during the Ebola outbreak not only violated the rights of women and girls at the time, but hampered Sierra Leone’s ability to rebuild for the future. The repercussions of the country’s policies have the potential to be longstanding. The crisis disproportionately affected women and girls—and women and girls must now be at the center of efforts to shape a lasting recovery.

Voices from the Field features contributions from scholars and practitioners highlighting new research, thinking, and approaches to development challenges. This article is authored by Dr. Daniela Ligiero, Vice President, Girls and Women Strategy at United Nations Foundation. On May 16, over 5,000 people from around the world (leaders, advocates, policymakers, journalists, and researchers) will descend upon Copenhagen for the fourth Women Deliver conference. In the world of international development, any conference that includes thousands of people, no matter how interesting or important the focus, is likely to receive some degree of criticism—ranging from questions about usefulness, cost, and objectives to outright eye rolling. But there are times when a conference like this is of critical importance. This is such a time. Last year, the world came together to adopt a new development framework, the Sustainable Development Goals (SDGs). To make the agenda a success, this year needs to be about moving from goals to action—moving from the “what” to the “how.” The focus of Women Deliver will be how to implement the SDGs so they matter most for girls and women. Here are the top three reasons why the Women Deliver conference matters for SDG implementation: Civil society matters. Civil society played a key role in the process leading up to the adoption of the global goals. Moving forward, there is a need to ensure that civil society continues to be engaged in both the implementation and monitoring of the agenda—exactly how this will happen is still not clear. The success of the SDGs depends on ensuring there is a social contract among various actors to move the agenda forward, so that we can keep each other accountable and learn from both successes and challenges along the way. There is great value in having civil society efforts that complement the official efforts of national governments and UN agencies to support, inform, and monitor progress on SDG implementation. Civil society, along with governments and the private sector, will be present at Women Deliver in full force. Integration matters. Women Deliver is not a conference about Goal Five (the stand-alone gender equality goal). Like the SDGs, it is dedicated to putting people at the center—in this case girls and women—to drive progress across all the goals. A key lesson from implementing the eight Millennium Development Goals is the need to move beyond operating in silos, or focusing exclusively on a single goal, while ignoring the relationships across goals. Implementing seventeen different agendas at once will be much more challenging and inefficient than doing so for eight. Women Deliver started as a conference focused on maternal health, but has smartly evolved. This year, in addition to sexual and reproductive health issues, there will also be a focus on economic empowerment, violence, education, and climate—and how all of these connect. Re-energizing matters. Getting the SDGs adopted took years of hard work, and those who engaged in the process started 2016 exhausted. The biggest risk to the success of the SDGs is the loss of momentum, drive, and passion. Working to empower girls and women can at times be tough, lonely, and draining. Women Deliver offers an important moment for actors around the world to re-energize and recommit themselves to the new sustainable development agenda. In the words of the conference organizers, Women Deliver 2016 will be a “fueling station where—onsite and online—we will learn from each other and leave with new ideas and inspiration, energized to push for ambitious action.” This will make us more powerful and effective.

The first time Senait went to school was when she was fifteen years old and it was entirely by accident. Last year, she left her small town in southern Ethiopia when her parents announced one day that a well-off man had asked to marry her, and they had agreed. Rather than attend school, Senait, the eldest of ten children, had to earn money for her family, so she sold food on the side of the road. Faced with the choice of marrying a man her father’s age, who already had twelve children, or paying a broker to illegally transport her to the Middle East for work, she chose work. So she left her town in the back of a truck, hopeful for the promise of greater opportunity in Kuwait. Things went wrong from the start. The broker told her he would take her to Addis Ababa and then onward to Kuwait by plane. Instead they drove south, and, when they reached Kenya, the broker coached her to convince the border officials she was visiting her brother in Nairobi. Once they reached Nairobi, the broker put her in a room with eight other girls and told her to wait as he got her a visa. For a month, the girls were given food and water and did not leave the room. When a few days passed without provisions, Senait left the house in search of water. She did not get far before the police picked her up. Senait called the broker from the station to ask for her passport. He hung up on her. The police transferred her to Heshima Kenya’s Safe House, a transitional shelter for unaccompanied refugee girls in Nairobi. For the first time in her life, she went to school and studied math, practiced reading, and learned some basic English. After ten months, her paperwork was ready that would allow her to return to Ethiopia. She was relieved to go home, but would miss her classes. Unfortunately, for many girls in Ethiopia and around the world, experiences like Senait’s are not uncommon. According to the United Nations, 62 million girls around the world are not in school and 150 million girls have experienced sexual violence. In the developing world, one in three girls is married before the age of eighteen. Among adolescent girls, medical complications from pregnancy and childbirth are a leading cause of death. A quarter of a billion adolescent girls live in poverty. As a result of structural cycles of poverty and violence, adolescent girls around the world like Senait migrate within their countries or to other countries to improve their economic opportunities. Migrants from Ethiopia are most likely to come from poor rural areas, be young and single, and in search of work. Some, like Senait, are younger than eighteen. While some go through legal channels, others pay illegal brokers to smuggle them out of the country, putting themselves at risk of sexual violence on the journey. Once they reach their employer’s home, many experience long hours, partial or delayed payment, and sexual or physical abuse. A recent report argues that adolescent girls’ experiences of poverty, exploitation, and violence shape their decisions to migrate and the risks they face doing it. While the Ethiopian government has taken important steps, more is needed to make legal migration safer, combat trafficking and illegal migration, and support rehabilitation services. Perhaps most importantly, girls like Senait need access to education and employment opportunities, the two major reasons they migrate in the first place—at the Safe House where Senait stayed in Nairobi with other girls from Ethiopia and the surrounding region, 70 percent had little to no schooling. African and international leaders have picked up the call to invest in adolescent girls like Senait, making the case that these investments benefit girls, their families, and their societies. Research from the United Nations and the International Monetary Fund finds that adolescent girls’ access to education is correlated with delayed marriage and childbearing, decreased HIV/AIDS rates, and greater gender equality. It improves the health of their children, and contributes to national income growth. These findings have spurred new action. At a national level, for example, the Ethiopian government vowed to eliminate child marriage—along with female genital mutilation, another harmful traditional practice—by 2025. To reach this goal, they secured a 10 percent increase in the national budget and mobilized more champions to build public support. International actors are joining in to complement such efforts and drive more resources and attention to the issue. A few weeks ago, the World Bank Group announced $2.5 billion in education projects for adolescent girls around the world, recognizing that their empowerment is central to achieving international development objectives. The U.S. government recently launched the Let Girls Learn initiative, along with a broader strategy to empower adolescent girls around the world. Adolescent girls also have taken more prominent roles in their societies and on the global stage to help guide the new investments and hold leaders accountable. When I met Senait, she had just arrived in Ethiopia from Nairobi, and expected to stay for a week at a transit center in Addis Ababa while her government, with the support of the International Organization for Migration, finalized the logistics for the return trip to her hometown. She planned to live with her aunt and save money to open a shop. If others ask her about her experiences, she’ll tell them not to try to reach the Middle East for work. And she will try to convince her parents to let her siblings wait until they’re older to get married. Despite her strength and optimism, Senait was going back to the same situation where she had no access to school and limited options to earn a living, and where there was little respect for her rights. Until this changes, girls like Senait will continue to risk abuse and exploitation as they migrate in pursuit of opportunity.

Last week at the Council on Foreign Relations, I hosted a roundtable with Jaha Dukureh, named by Time magazine as one of the 100 most influential people of 2016 for her work advocating against female genital mutilation/cutting (FGM/C). Along with Dukureh, Acting U.S. Special Envoy to the Organization of Islamic Cooperation Arsalan Suleman led the discussion following a screening of Jaha’s Journey, an inspiring documentary about Dukureh’s own struggle as a survivor of FGM/C who was forced to marry at fifteen years old. Dukureh has since become a leading advocate against FGM/C, first in the United States (her adopted home), then in the Gambia (her home country), and now abroad. Roughly 200 million girls and women worldwide today have undergone FGM/C, with another estimated three million girls at risk of FGM/C annually. Dukureh, a survivor of FGM/C, first came to prominence in 2014 when she began a Change.org petition, calling for the U.S. government to commission a study on the prevalence of FGM/C in the United States. The petition received over 220,000 signatures and resulted in the Obama administration commissioning a study, released earlier this year, to assess the number of women and girls at risk of FGM/C in the United States. After the success of her Change.org petition, she founded Safe Hands for Girls, an organization that works to empower and educate girls and women about FGM/C. Dukureh also supported a youth-led movement against FGM/C in the Gambia in 2014, which played a large role in the Gambian government banning the practice a year later in 2015. During our CFR roundtable, both Dukureh and Suleman noted the importance of working with both religious leaders as well as with men and boys in ending FGM/C. In many communities, men hold a considerable amount of power and are often the primary decision-makers. Some also believe that FGM/C is a religious practice. Dukureh’s experience demonstrates that religious leaders speaking out against FGM/C— and highlighting that it is not mandated by religious doctrine—can go a long way in stopping FGM/C. Dukureh also discussed how the framing of FGM/C as an “African problem” obscures the reality that FGM/C is global in scope. She highlighted indigenous groups in South America and the largely South Asia-based Dawoodi Bohras as examples. Engaging nontraditional allies for women’s rights, including men and boys as well as religious leaders, in the discussion and efforts against FGM/C is a vital aspect of ending this harmful practice against women. Samantha Power (L), United States Ambassador to the United Nations, Jaha Dukureh (C), and Maryum Saifee (R). Photo courtesy of Maryum Saifee

Voices from the Field features contributions from scholars and practitioners highlighting new research, thinking, and approaches to development challenges. This article is authored by Serra Sippel, president of the Center for Health and Gender Equity. Healthy women and girls are the cornerstones to building communities that are safe, just, and thriving; and rights-based maternal health care is the linchpin to realizing women’s health and rights. Yet women are dying and suffering debilitating disease and injury during pregnancy and childbirth due to preventable causes: they bleed to death, acquire infections, have underlying but treatable health conditions, or obtain unsafe abortions. The fact is that becoming pregnant is still one of the most dangerous things a woman can do in her lifetime. Every woman has a right to safe motherhood and the way forward to improving maternal health is not a mystery. A new ninety-second video released by the Center for Health and Gender Equity (CHANGE) highlights six fundamental barriers to advancing maternal health: Unmet need for family planning. If all women with unmet need for modern methods of contraception were using it, global maternal mortality would be reduced by nearly one-third. Underlying health conditions. Women living with HIV have an eight-times-greater risk of death in pregnancy than HIV-negative women, as well as an increased risk of acquiring other infections during pregnancy, childbirth, and the postpartum period. Unsafe abortion. Over twenty-one million women around the world—the majority of whom live in developing countries—experience unsafe abortions each year, the complications of which cause thirteen percent of all maternal deaths. Disrespect and abuse. Women choose to give birth at home not just because they live too far from health facilities or because they can’t afford treatment, but because they have experienced (or fear they will experience) humiliation, maltreatment, or discriminatory and substandard care. Human rights violations. Child marriage, female genital cutting, and other forms of gender-based violence vastly increase the health risks of pregnancy and childbirth. Weak health systems. In most countries with high maternal mortality ratios, health workers are poorly trained, and inadequately paid, facilities lack access to basic equipment and commodities, and infrastructure such as roads, electricity, and sanitation are unreliable. To break these barriers to maternal health, we need greater leadership and a coordinated global movement to advance the health and human rights of all women and girls. That is why advocates, non-governmental organizations, health care providers, and policymakers from around the world are recognizing International Day for Maternal Health and Rights. Earlier this month, more than 350 organizations and individuals from around the world joined the call on the United Nations to recognize April 11 as International Day for Maternal Health and Rights. We must all add our voices to this call and stand up for women and girls and for respectful maternal health care. When the health and rights of all women and girls are respected, protected, and honored, they can live the lives they want and build communities that are safe, just, and thriving; and that means a better world for all.

Voices from the Field features contributions from scholars and practitioners highlighting new research, thinking, and approaches to development challenges. This article is authored by Jocelyn Kelly, the director of Harvard Humanitarian Initiative’s (HHI) Women in War program. Last month, the International Criminal Court (ICC) convicted former Congolese Vice President Jean-Pierre Bemba of crimes against humanity and war crimes perpetrated by his rebel group, the Congolese Liberation Movement (MLC). It is a breakthrough case for a number of reasons. It establishes the strongest precedent to date for holding high-level commanders responsible for the actions of their soldiers, even when controlling troops from a distance, and it is the first ICC case that puts a spotlight on prosecuting sexual violence as a war crime. The United Nations tribunals for war crimes in the former Yugoslavia and in Rwanda have passed down high-profile convictions for rape as a war crime and crime against humanity, but this marks the first time the ICC has prosecuted rape as a crime against humanity. Questions about command and control are central to the prosecution of high-level commanders. Yet, the higher up the chain of command a leader is, the harder it can be to prove that a leader has direct control over their soldiers’ actions. As someone who has interviewed rebel commanders in central Africa about the topic of sexual violence for the past ten years, I understand the importance of looking at the behaviours and motivations of soldiers and their commanders, as well as the pitfalls and complexities of this task. The motivations of a rebel group can vary drastically based on the personalities of sub-commanders, on the current political climate, on timing within a conflict, and on the kind of relationship that rebels have established with civilians. The soldiers I talked to in the Mai Mai rebel group in eastern Democratic Republic of Congo (DRC) emphasized that even within a small sub-unit, soldiers’ motivations to rape varied from personal motivations, to a result of orders to bring back sex slaves, to its use as a tool to exert control over a population. In cases of personally motivated rape, commanders may turn a blind eye or tacitly condone such behavior, but, in more organized campaigns of abuse, there is a clear message from higher command. Soldiers I interviewed in DRC said if such orders were disobeyed, they would be punished. Dr. Elisabeth Wood at Yale has investigated the diverse profiles of violence exhibited by non-state armed groups. Some can effectively restrain certain types of violence, while other groups wield some types of “signature” abuses as ways to terrorize and subjugate populations. In the past, leaders who have promoted rape—whether by ignoring, condoning, or actively encouraging it—have largely escaped prosecution. It has been difficult to definitively prove that commanders ordered human rights abuses committed by their soldiers. These complexities—the fact that violence can change over time, across space, and in reaction to decisions made by sub-commanders—has made it extraordinarily difficult to prosecute crimes at the highest levels of command. Bemba tried to exploit this difficulty by claiming that he remained in Democratic Republic of the Congo while his troops had moved into neighboring Central African Republic, where some of the most systematic and horrific abuses were committed. The court found that throughout the group’s campaign of terror from 2002-2003, Bemba maintained full control over his troops—a pattern established by MLC intelligence reports, logs of communications, local and international media accounts, and non-governmental organizations’ reports. This represents a breakthrough in war crimes conviction: a commander who controlled his troops largely from a different country was still found legally culpable for his actions. This method of establishing responsibility for command and control is a new frontier in the ICC’s capacity to hold perpetrators of war crimes and crimes against humanity responsible for their actions, particularly as the crime of sexual violence in conflict gains more attention. For the past two years, I have been traveling to countries where the Lord’s Resistance Army (LRA) has been active. The LRA is notorious for its conscription of child soldiers, brutal abuse of civilians, and long campaign of sexual slavery of women and girls. In 2005, the ICC issued an arrest warrant for Joseph Kony, the group’s notoriously elusive leader. As the LRA has dispersed more and more widely across remote regions in central Africa, some have wondered whether Kony’s control over the group has loosened. However, a recent report published by my research group clearly documents the acute control Kony wields over his troops to this day. I have spoken with recently demobilized high-level combatants, former child combatants, and women and girls who have escaped the group. The message is resoundingly clear—that Kony continues to control from afar even the most minute aspects of group life, from dietary restrictions to where to travel, and exactly what kind of atrocities to commit. The Bemba precedent will make it easier to convict leaders like Kony if and when they are brought to justice in the future. The March ICC decision was momentous. It signals not an incremental gain in the movement to prosecute sexual violence as a war crime—it is an unprecedented stride forward in holding the highest-level leaders accountable for the crimes they orchestrate.

Welcome to “Women Around the World: This Week,” a series that highlights noteworthy news related to women and U.S. foreign policy. This week’s post, covering February 19 to February 26, was compiled by Anne Connell, Dara Jackson-Garrett, and Alexandra Eterno. End of India’s sterilization policy                                             The government of India announced this week that it will end its decades-long reliance on the sterilization of women as a primary mode of contraception and population control. The policy shift will affect millions of Indian women: four million women per year undergo tubal ligations, many with cash incentives paid by state governments at sterilization camps. After twelve women died and dozens more were sickened from botched sterilizations in 2014, public opinion and national political will in support of alternative contraceptive options began to grow. Following this week’s announcement, government-run health facilities around the country will introduce free injectable contraceptives for women. International health organizations have long advocated for new and more accessible birth control options for women in India and around the world: complications due to pregnancy and childbirth are the second leading cause of death for girls fifteen to nineteen years old globally, and research shows that 30 percent of maternal deaths could be prevented if women were able to space pregnancies two or more years apart. Innovation in HIV prevention                                                                                     Findings from two major HIV studies released at a Boston conference on Monday and published in the New England Journal of Medicine offer promising evidence of the success of a new HIV-prevention method for women. A flexible and inexpensive insertable ring that slowly releases an antiviral drug has been shown to significantly lower the rate of HIV contraction from sexual partners. The two studies—The Ring Study clinical trial and a sister study called ASPIRE—involved over 4,500 women between the ages of eighteen and forty-five in Malawi, South Africa, Uganda, and Zimbabwe. The new ring did not eliminate transmission, but overall infection rates fell by between 27 percent and 31 percent in the trial groups. Researchers suggest that this represents one of the most significant advances to date in HIV prevention for African women: women make up nearly 60 percent of those living with the virus in sub-Saharan Africa. Rise in child marriage among Syrian refugees                                                                 New evidence suggests that rates of child marriage are climbing among Syrian refugees living in neighboring countries. Official data show that the number of girls married under the age of eighteen in Jordan’s refugee communities has risen steadily each year since the outbreak of conflict, from 12 percent in 2011 to 32 percent in 2014. In 16 percent of these cases, men married girls who were 15 or more years younger. Anecdotal evidence suggests that the prevalence of child marriage may be higher in reality than official data show, given the sizeable number of unregistered marriages. Even as some Syrian parents report awareness of the risks of child marriage and resistance to the practice, families are increasingly using child marriage as a coping mechanism to counter insecurity caused by conflict and mass displacement. Financial stress, fears of child labor, food insecurity, and parents’ desires to protect daughters from sexual violence in refugee camps factor into decisions to push girls into marriages; however, evidence shows that this practice only serves to exacerbate poor development outcomes in places already overwhelmed by complex challenges.  

Welcome to “Women Around the World: This Week,” a series that highlights noteworthy news related to women and U.S. foreign policy. This week’s post, covering February 5 to February 11, was compiled by Becky Allen, Dara Jackson-Garrett, and Alexandra Eterno. Aung San Suu Kyi may assume presidency Myanmar may see its first woman president following “positive” talks between the country’s military chief and Aung San Suu Kyi, a Nobel Peace? Prize winner and leader of Myanmar’s National League for Democracy (NLD). The NLD already won national elections by a landslide in November, bringing an end to five decades of military rule. However, Suu Kyi is currently constitutionally barred from assuming the presidency due to a provision prohibiting anyone with a foreign spouse or child from serving as president. To overturn this restriction, the NLD must secure a two-thirds majority vote in parliament; this requires consent by the military, which still holds twenty-five percent of parliamentary seats. While members of the NLD have expressed optimism about securing this change, the outcome remains uncertain. Women now represent one-third of UAE cabinet The newly appointed UAE cabinet includes five women, bringing the total number of women in the twenty-nine member cabinet to a record of eight. Shamma al Mazrui, the twenty-two year old Minister of State for Youth Affairs, will become the youngest minister in the world; she will also lead the UAE Youth National Council. As part of the cabinet shakeup, the government created new ministries for Tolerance, the Future, Youth, Happiness, and Climate Change, and added two new ministers to assist with education. This shift toward youth and gender equality is part of the largest structural change in the country’s history, suggesting a new future for the UAE government. Surge in teenage pregnancy tied to Ebola outbreak Several West African countries, including Sierra Leone, Liberia, and Guinea, experienced a dramatic increase in sexual violence against women during the 2014 Ebola epidemic, causing the number of teen pregnancies to rise in its aftermath. While precise data are difficult to obtain due to stigmatization and underreporting, a study by the United Nations Development Program indicates that the number of teen pregnancies in Sierra Leone increased by as much as sixty-five percent. Globally, complications during pregnancy and childbirth are the second leading cause of death for girls ages fifteen to nineteen. When a girl becomes pregnant she is more likely to end her education, her job prospects decrease, and her health can suffer. While Ebola has all but dissipated in West Africa, with Sierra Leone discharging its last patient earlier this week, the effects of the surge in sexual violence and teen pregnancy during the Ebola epidemic will be long term.

In response to the rapid spread of the Zika virus and the increasing number of cases linking the virus to microcephaly—a birth defect frequently characterized by a small head and incomplete brain development—some Latin American and Caribbean governments are urging women to delay having children. In El Salvador, for example, the deputy health minister made headlines when he urged women to refrain from becoming pregnant until 2018. Yet throughout the region, women’s reproductive rights and access to health care  are limited, and in 2014, more than half of the region’s pregnancies were unplanned. For instance, in El Salvador—which has one of the highest teen pregnancy rates in Latin America—one in three babies are born to girls between the ages of ten and nineteen, often as a result of unplanned pregnancies. These factors make calling for women to hold off on getting pregnant an impractical solution at best. Last week, the World Health Organization (WHO) declared the virus an international public health emergency, citing the virus’ possible connection to microcephaly as its primary concern. Governmental health organizations, including the Center for Disease Control and Prevention (CDC), have warned pregnant women and women trying to become pregnant to consider not traveling to countries with Zika. Spread by the Aedes aegypti mosquito, the Zika virus has so far hit Brazil the hardest. As the Council on Foreign Relations’ global health expert Laurie Garrett notes, Brazil’s health minister has already warned that Zika has gone from being an epidemic to endemic disease in his country, which means that Zika may be taking hold permanently, potentially threatening thousands of babies per year. For Brazil, the virus and recommendations against traveling couldn’t come at a worse time. Brazil is stepping up eradication efforts in advance of the 2016 Olympic Games, which it is hosting in Rio de Janeiro this August. But fears about the virus have continued to grow and could threaten the upcoming games. Moreover, travel warnings could have a negative economic impact on the region, given the dependence many countries have on tourism as well as business travel. Authorities in Dallas, Texas, recently reported a case of the Zika virus transmitted by sex, rather than a mosquito bite, in a case involving an individual who returned recently from Venezuela.  In response last week, the CDC issued interim guidelines for preventing sexual transmission of Zika virus.  Noting the Texas case, the CDC guidance recommends that men “who reside in or have traveled to an area of active Zika virus transmission and their pregnant sex partners should consistently and correctly use condoms during sex...or abstain from sexual activity for the duration of the pregnancy.” In prior cases, evidence suggested that the Zika virus had been sexually transmitted or found in semen. However, in addition to confronting restrictions on reproductive rights and limited access to reproductive health services, women who are less-educated or live in remote areas throughout the Americas typically lack sex education. Not only do they frequently have insufficient information about and access to contraception and family planning, these women (and men) may not be well-informed about the importance of safe sex to prevent sexually transmitted diseases (STDs). Additionally, women often face cultural barriers or lack power in relationships, which may undercut their ability to insist on contraception and safe sex.  While years of HIV/AIDs prevention campaigns have driven home the point on STD-prevention for the better-educated, cosmopolitan, urban elites, such campaigns are less likely to have reached women who live in poor or remote communities with less access to news and information. A further problem women face is sexual violence, which can cause unplanned pregnancies and the spread of STDs. Citing El Salvador’s high rates of sexual violence, Human Rights Watch’s Amanda Klasing notes, “Calling on women to delay their pregnancy might be prudent[,] [b]ut many women and girls in the region don’t have control over when they get pregnant.” Other rights groups say that El Salvador’s high teen pregnancy rate is in part because of rape by stepfathers, relatives, and gang members, and that brutal sexual violence is a particular problem in light of street gangs that use rape to control women and girls as well as to terrorize local communities, extort money, and silence opposition. Monica Roa, vice president of strategy for Women’s Link Worldwide, calls it “incredibly naive for a government to ask women to postpone getting pregnant in a context such as Colombia where more than 50 percent of pregnancies are unplanned and across the region where sexual violence is prevalent." Tackling the Zika crisis will require addressing the region’s broader challenges concerning women’s equality and public health, including high rates of sexual violence, limited access to women’s health care services, and lack of family planning information.

Welcome to “Women Around the World: This Week,” a series that highlights noteworthy news related to women and U.S. foreign policy. This week’s post, covering January 21 to January 28, was compiled by Anne Connell and Becky Allen. UNHCR cites dangers for refugee women and girls            A new report from the UN High Commissioner for Refugees (UNHCR) finds that women and girl refugees en route to Europe face “grave protection risks.” Representatives of the UNHCR, the UN Population Fund (UNFPA), and the Women’s Refugee Commission (WRC) carried out a joint mission in Greece and Macedonia to develop practical recommendations to strengthen responses by EU institutions, governments, and humanitarian actors to risks, including extortion and exploitation, sexual assault, human and organ trafficking, theft, and poor health outcomes. The report also finds that the policy response to the refugee crisis is unable to “prevent or respond to sexual and gender-based violence survivors in any meaningful way.” Female refugees lack safe spaces, gender-segregated sleeping areas, water, sanitation and hygiene (WASH) facilities, psychosocial support, and Farsi and Arabic translators. These concerns are particularly timely as demographics shift: in January 2016, 55 percent of arrivals to Europe were women and children, compared to just 27 percent in June 2015. Zimbabwe court outlaws child marriage                                                                        This week, Zimbabwe’s Constitutional Court outlawed marriage under the age of eighteen in a ruling on a case brought by two former child brides. The plaintiffs, Loveness Mudzuru and Ruvimbo Tsopodzi, were among the 32 percent of Zimbabwean girls married as children. This represents one of the highest rates of the practice among southern African countries, though still lower than in neighboring Malawi, Mozambique, and Zambia, which all rank in the world’s top twenty child marriage hot spots. Although the Zimbabwean constitution ratified in 2013 ruled that no person could be forced into marriage against their will, the country’s Marriage Act continued to allow girls as young as sixteen to legally enter marriage with parental consent. The court’s new ruling, which enforces the constitutional age limit of eighteen for matrimony, comes on the heels of active civil society campaigns and the first African Girls’ Summit on child marriage, held in November 2015. Laws setting a minimum age of marriage are just one tool in the range of measures needed: the practice is driven by poverty, cultural traditions, and pervasive discrimination against girls, which need to be addressed by a combination of legislation, enforcement measures, and civic education. Zika virus poses risks to pregnant women                                                                         As concern over the Zika virus spreads in Latin America and the Caribbean, health officials in El Salvador took an unprecedented step this week: advising all women to delay pregnancy until 2018 in order to mitigate chances of birth defects associated with the virus. Though only one in five people infected with the Zika virus become ill, and symptoms typically include only mild fever, rash, and joint pain, new evidence points to devastating effects of the virus on pregnant women. In El Salvador alone, 492 cases of Zika have been diagnosed. Cases of the mosquito-borne virus have been documented in twenty four other countries across the region, and the spread shows no signs of abating, despite new travel warnings and scientific research designed to curb it.

Amidst final negotiations over the Sustainable Development Goals, both private and public sector development funders are turning their attention to the gap between this ambitious agenda and available resources. Last week, government, business, and NGO representatives gathered in Addis Ababa, Ethiopia for the Third Financing for Development Conference to devise ways to support this new development agenda. One proposal is to support innovation to fuel cost-effective approaches to development. On the eve of the Addis conference, I hosted a roundtable at the Council on Foreign Relations with a pioneer of development innovation: Ann Mei Chang, executive director of the Global Development Lab at the U.S. Agency for International Development (USAID). Launched in April 2014, the Global Development Lab is USAID’s newest entity, designed to fund breakthrough innovations to “accelerate development impact faster, cheaper, and more sustainably.” Such a broad mandate requires both flexibility and a willingness to fail—two characteristics not traditionally associated with government agencies. The Global Development Lab takes a venture capital-style approach to funding development. It crowdsources solutions from around the globe, including from individuals and organizations that have never before worked with USAID. The Lab makes high-risk, low-cost investments in projects, with the potential to increase funding for those that show promise. By experimenting and “failing small,” the Lab can take on more risk than the average government aid funder. Some have expressed skepticism about the power of innovation to accelerate development gains. Bill Gates, for example, has criticized models that emphasize tech innovations too heavily as potentially distracting from perpetual development challenges, such as a lack of sanitation infrastructure or access to basic health services. In fact, while the Global Development Lab does support projects that are technically advanced, some of the most successful initiatives simply improve upon common solutions and existing knowledge by permitting the flexibility to innovate. For example, in one Lab-funded project, the NGO Evidence Action explored how to enhance the uptake of chlorine to disinfect drinking water and prevent diarrhea, which is the cause of death for an estimated 760,000 children under five each year. Despite widespread acknowledgment of chlorine’s efficacy, uptake stands at less than ten percent around the world. In an attempt to improve this number, innovators from Evidence Action came up with an idea called the chlorine dispenser, a low cost machine installed in areas with community water services. With the push of a button, the dispenser distributes an appropriate amount of chlorine into a bucket or jerrican. This simple innovation has already had an outsized impact: in areas where it is operational, including Kenya, Malawi, and Uganda, it has increased the use of chlorine to nearly 50 percent. Other projects funded by the Lab stem from unlikely sources and test unexpected methods. One intervention dreamed up by a car mechanic in Argentina—called the Odón Device—became a potentially life-saving tool to assist with obstructed labor. The device, which is now in development at Becton, Dickinson and Company, features a plastic bag which inflates around the baby’s head in the womb and is pulled until it emerges. The innovator, Jorge Odón, first thought of the idea after watching a YouTube video that showed how to extract a cork stuck inside an empty wine bottle. This device is considered safer than vacuum assist and forceps, which are even more dangerous when used by inexperienced practitioners in low-resource settings. While these out-of-the-box ideas have the potential to accelerate development gains, one of the Lab’s greatest challenges is how to measure impact—particularly in areas such as democracy, human rights, and governance. The Lab is piloting sensors and mobile surveys in an attempt to obtain timely and gender-disaggregated data, but more work is certainly needed. Though the Lab is still a work in progress, its approach to innovation in development is a model to consider incorporating into the next stage of development funding.

This year—2015—is an auspicious moment for global development. In September, as the Millennium Development Goals (MDGs) expire, UN member states will adopt a new framework that will guide international development over the next fifteen years. In advance of the fall summit on the Sustainable Development Goals (SDGs)—as well as the upcoming Third International Financing for Development Conference in Addis Ababa, Ethiopia—I hosted Thomas Gass, assistant secretary-general for policy coordination and inter-agency affairs at the UN Department of Economic and Social Affairs, and Ambassador Elizabeth Cousens, deputy chief executive officer at the United Nations Foundation and former U.S. chief negotiator on the SDGs, to discuss gender equality and the future of the international development agenda. It is indisputable that over the past fifteen years the MDGs have contributed to advancement for women and girls—particularly in the area of maternal health, where mortality rates have been halved, and in access to primary education, where the global gender gap has virtually closed. However, many argue that the MDGs could and should have done more to improve the status of women and girls. Several issues critical not only to women’s progress, but also to overall prosperity and stability—such as child marriage, violence against women, and valuation of women’s work—were overlooked. The SDGs afford a critical opportunity to dramatically expand upon progress for women and girls and increase our collective ambition for achieving gender equality. Importantly, early drafts of the SDGs include a specific gender equality goal with targets that are considerably more comprehensive than those included in the MDG framework, and issues related to the advancement of women and girls have been integrated throughout the post-2015 goals. Yet questions remain over the implementation of the proposed SDGs. The UN zero draft of the SDGs released earlier this month includes seventeen goals and 169 targets. Given the high number of goals and targets, how will countries prioritize their efforts? And how can global actors ensure attention to gender equality—an issue that is too often siloed or overlooked, despite considerable evidence of the connection between women’s progress and development? There have been encouraging signs that the commitment to gender equality outlined in the SDGs is strong. During our conversation last week, former Ambassador Cousens noted that the goal on gender equality was the first on which government and civil society groups reached a consensus during the initial stages of the Open Working Group process that formed the basis of the SDG zero draft. But the real test of this commitment will be the extent to which gender equality targets are financed, and how member states are held accountable. Indicators of progress for the SDGs will not be adopted until next March, and although the current proposal includes many references to women and girls, it is unclear whether some potentially contentious issues—for example, female genital mutilation—will survive the negotiation process. The comprehensive gender equality targets included in the SDG zero draft are a positive step forward for the post-2015 development agenda. The promise of this framework, however, will only be realized if member states and development practitioners are held accountable for financing and implementing progress toward the equality of women and girls.

This year—2015—is an auspicious moment for global development. In September, as the Millennium Development Goals (MDGs) expire, UN member states will adopt a new framework that will guide international development over the next fifteen years. In advance of the fall summit on the Sustainable Development Goals (SDGs)—as well as the upcoming Third International Financing for Development Conference in Addis Ababa, Ethiopia—I hosted Thomas Gass, assistant secretary-general for policy coordination and inter-agency affairs at the UN Department of Economic and Social Affairs, and Ambassador Elizabeth Cousens, deputy chief executive officer at the United Nations Foundation and former U.S. chief negotiator on the SDGs, to discuss gender equality and the future of the international development agenda. It is indisputable that over the past fifteen years the MDGs have contributed to advancement for women and girls—particularly in the area of maternal health, where mortality rates have been halved, and in access to primary education, where the global gender gap has virtually closed. However, many argue that the MDGs could and should have done more to improve the status of women and girls. Several issues critical not only to women’s progress, but also to overall prosperity and stability—such as child marriage, violence against women, and valuation of women’s work—were overlooked. The SDGs afford a critical opportunity to dramatically expand upon progress for women and girls and increase our collective ambition for achieving gender equality. Importantly, early drafts of the SDGs include a specific gender equality goal with targets that are considerably more comprehensive than those included in the MDG framework, and issues related to the advancement of women and girls have been integrated throughout the post-2015 goals. Yet questions remain over the implementation of the proposed SDGs. The UN zero draft of the SDGs released earlier this month includes seventeen goals and 169 targets. Given the high number of goals and targets, how will countries prioritize their efforts? And how can global actors ensure attention to gender equality—an issue that is too often siloed or overlooked, despite considerable evidence of the connection between women’s progress and development? There have been encouraging signs that the commitment to gender equality outlined in the SDGs is strong. During our conversation last week, former Ambassador Cousens noted that the goal on gender equality was the first on which government and civil society groups reached a consensus during the initial stages of the Open Working Group process that formed the basis of the SDG zero draft. But the real test of this commitment will be the extent to which gender equality targets are financed, and how member states are held accountable. Indicators of progress for the SDGs will not be adopted until next March, and although the current proposal includes many references to women and girls, it is unclear whether some potentially contentious issues—for example, female genital mutilation—will survive the negotiation process. The comprehensive gender equality targets included in the SDG zero draft are a positive step forward for the post-2015 development agenda. The promise of this framework, however, will only be realized if member states and development practitioners are held accountable for financing and implementing progress toward the equality of women and girls.

Last week, the government of Malawi took a big step toward protecting its girls and strengthening its families: it increased the legal age of marriage to eighteen. Previously, girls in Malawi were allowed to marry at sixteen or, with parental consent, at fifteen. The UN Population Fund reported that Malawi has the seventh highest rate of child marriage in the world, with half of all girls married before their eighteenth birthday, and nearly one in eight married by age fifteen. A 2014 Human Rights Watch report noted that in Malawi child marriage is often seen as a way to improve a family’s economic status, protect daughters from adolescent pregnancy—which is highly stigmatized—and ensure a family’s honor. Yet for girls, child marriage poses severe education and health risks. After girls are married, it is unlikely that they will continue to attend school. In parts of Sub-Saharan Africa and South Asia, child marriage has been shown to lower the likelihood that girls will achieve literacy. Furthermore, child marriage exposes girls to all of the risks associated with early pregnancy and childbirth. Girls aged fifteen to nineteen are twice as likely to die from causes related to pregnancy or childbirth than women in their twenties, and girls under age fifteen are five times more likely to die. According to the World Health Organization, teenage pregnancy accounts for 20 to 30 percent of maternal deaths in Malawi. This makes the unanimous passage of the Divorce, Marriage, and Family Relations Bill by their parliament a positive step in improving the lives of women and girls in Malawi. Yet more remains to be done. As former President of Malawi Joyce Banda said at a recent CFR roundtable I hosted on child marriage, “In Malawi this week, we have finally passed the bill of banning child marriage… But the passing of the bill is just the first step… Passing the bill is one thing, but implementing is yet another problem.” Civil society groups warn that the practice of child marriage cannot truly become a thing of the past without programs to eliminate poverty and change other local practices. For example, in parts of Malawi, girls reaching puberty may receive a night-time visit from an older man—known as a “hyena”—with the intent of preparing them for marriage. There are a variety of strategies available to governments facing high child marriage rates—such as Malawi—to further their push to end child marriage. These include community-based initiatives that mobilize local leaders as well as men and boys to change social norms, programs that focus on returning girls to school after marriage or providing them with vocational training, and conditional cash transfer programs that encourage parents to keep their daughters unwed and in school. Ending child marriage will not only allow girls to reach their full potential, it will also contribute to healthier families and improve Malawi’s economic growth as these girls are able to contribute fully to their society.

Last week, the government of Malawi took a big step toward protecting its girls and strengthening its families: it increased the legal age of marriage to eighteen. Previously, girls in Malawi were allowed to marry at sixteen or, with parental consent, at fifteen. The UN Population Fund reported that Malawi has the seventh highest rate of child marriage in the world, with half of all girls married before their eighteenth birthday, and nearly one in eight married by age fifteen. A 2014 Human Rights Watch report noted that in Malawi child marriage is often seen as a way to improve a family’s economic status, protect daughters from adolescent pregnancy—which is highly stigmatized—and ensure a family’s honor. Yet for girls, child marriage poses severe education and health risks. After girls are married, it is unlikely that they will continue to attend school. In parts of Sub-Saharan Africa and South Asia, child marriage has been shown to lower the likelihood that girls will achieve literacy. Furthermore, child marriage exposes girls to all of the risks associated with early pregnancy and childbirth. Girls aged fifteen to nineteen are twice as likely to die from causes related to pregnancy or childbirth than women in their twenties, and girls under age fifteen are five times more likely to die. According to the World Health Organization, teenage pregnancy accounts for 20 to 30 percent of maternal deaths in Malawi. This makes the unanimous passage of the Divorce, Marriage, and Family Relations Bill by their parliament a positive step in improving the lives of women and girls in Malawi. Yet more remains to be done. As former President of Malawi Joyce Banda said at a recent CFR roundtable I hosted on child marriage, “In Malawi this week, we have finally passed the bill of banning child marriage… But the passing of the bill is just the first step… Passing the bill is one thing, but implementing is yet another problem.” Civil society groups warn that the practice of child marriage cannot truly become a thing of the past without programs to eliminate poverty and change other local practices. For example, in parts of Malawi, girls reaching puberty may receive a night-time visit from an older man—known as a “hyena”—with the intent of preparing them for marriage. There are a variety of strategies available to governments facing high child marriage rates—such as Malawi—to further their push to end child marriage. These include community-based initiatives that mobilize local leaders as well as men and boys to change social norms, programs that focus on returning girls to school after marriage or providing them with vocational training, and conditional cash transfer programs that encourage parents to keep their daughters unwed and in school. Ending child marriage will not only allow girls to reach their full potential, it will also contribute to healthier families and improve Malawi’s economic growth as these girls are able to contribute fully to their society.