Challenges of Poverty on Sexual Reproductive Health

This paper reflects on the challenges of poverty on sexual reproductive health in Botswana. It intends to stimulate discussions on issues surrounding poverty and sexual reproductive and how to alleviate such challenges. The challenges explored include: lack of information on Sexual Reproductive Health Rights (SRHR); poor access to SRHR; lack of negotiation skills for sexuality, and adolescents in poverty and SRHR. The paper starts with an overview of poverty in Botswana, then discusses the challenges of poverty on sexual and reproductive health rights and lastly, the recommendations that intend to address the challenges of poverty related to SRHR.


218
Women who have not completed at least high school are at risk for poor health (Gibbs & Engebretson, 2013). This paper focusses on the challenges of poverty in relation to sexual reproductive health and rights. Challenges addressed in this paper are: Lack of information on SRHR; poor access to sexual and reproductive health right services; lack of negotiation skills related to sexuality issues; poverty in adolescents as well as pregnancy.

Lack of information / knowledge on SRHR
Education plays a major role in decision making and being equipped with a wide range of information is a great benefit to an individual. Similarly, being knowledgeable about information related to SRHR is an advantage and an enabler to making rational and informed choices with regard to sexual and reproductive health matters. On the contrary, living in poverty deprives individuals to acquire information related to SRHR services that is equally obtainable by other people. SRHR services include family planning, ante natal, intrapartum, post-natal and neonatal care (Ministry of Health, 2008). As a result, people living in poverty lack information and understanding of SRHR services being offered.
Missing out on pertinent and crucial information needed for one's entire life concerning reproductive health results in either underutilization or non-utilization of services. Engaging in risky sexual behaviours without full understanding of the consequences of their commissions or omissions of their acts is a common observation among people living in poverty. For example, lack of information on the appropriate use of condoms increases the likelihood of its non-utilization. Failure to use condoms greatly increases the likelihood of acquiring sexually transmitted infections including HIV and AIDS which potentially increases the morbidity and mortality rates.

Poor access to sexual and reproductive health right services
Access to SRHR services by people living in poverty is very crucial. Accessibility is the availability of good health services within reach of those who need them and of opening hours, appointment systems and other aspects of service organization and delivery that allow people to obtain the services when they need them (WHO,2015). People living in poverty hardly access SRHR services largely due to lack of knowledge on what is available, where and how to access such. Failure to access family planning services often results in too large families. The poor tend to have larger families than the rich, they are prone to illnesses, and insufficient utilisation of health care services, such as family planning and care during pregnancy (Izugbara and Ngilagwa, 2010). They also experience financial limitations. For instance, lack of resources to pay for transportation to reach the health facilities where they access quality care at critical moments (Roudi-Fahimi and Ashford, 2005). People living in poverty are also not likely to access screening services for cancer such as the ´see and treat´ that are intended to reduce the morbidities and mortalities associated with cancer. Results of a study conducted in Egypt, reflect that the percentage of births attended by medically trained personnel were (31% in the poorest fifth, 61% in the middle fifth and 94% in the richest fifth. These results reflect that the poorest fifth were the lowest in attendance. Poverty hampers women's ability to use available maternal care services. (Roudi-Fahimi and Ashford, 2005).

Lack of negotiation skills related to sexuality issues
SRHR knowledge, negotiation skills and one's confidence are key in fruitful negotiations related to sexuality issues. Limitations in these aspects as often is the case in people living in poverty hinder them from engaging in discussions related to sexual reproductive health matters. The ability of poor women to negotiate for safer sex is limited, therefore, they are at risk of being overpowered by their male counter parts during SRHR discussions. This is most likely when they are economically dependent on their male partners. The end results of failed negotiations is the occurrence of unplanned and unwanted pregnancies. The unwanted pregnancies are most likely to induce stress among females which may ultimately lead to both ante and post-partum distress. Unplanned pregnancies increase the risks of depression among mothers and stress related to parenting (Bahk, et al, 2015) Adolescents in poverty and sexual reproductive health Adolescent's sexual reproductive health and poverty are still a public health challenge. In sub-Saharan Africa, Botswana inclusive, adolescents get married at a younger age that is as early as 16 years. In addition, adolescent childbearing, HIV transmission and low coverage of modern contraceptives are common factors affecting adolescents in sub-Saharan countries. According to Melesse et al 2020, adolescents do not have access to Sexual reproductive services as a result of lack of resources such as transportation and money. A lot of adolescents are not reached in terms of services. There are inequalities in adolescents by gender, education, urban rural residence and household wealth that is the poorest and the richest as this is persisting, and the issue need to be addressed. In

Poverty and pregnancy
Other attributes have shown that poorer women have been depressed by lack of resources and resorted to the use of alcohol, tobacco, and other harmful substances. This led to higher risk for food insufficiency and insecurity and poor feeding practices and habits (Izugbara and Ngilagwa. 2010). Living in poverty has profound effects on the expectant woman and her family and it is likely to increase the risk of adverse pregnancy outcome (Kim et al, 2018). Poverty is associated with reduced financial independence of one's ability to sustain pregnancy needs especially in terms of food and nutrition. Malnutrition is one of the common conditions found among pregnant women living in poverty. Malnutrition is either a deficient or an excess of intake of nutrients which may result in undernutrition or overweight respectively (WHO, 2016). Pregnant women living in poverty are also prone to developing nutrient deficiency related conditions such as anaemia. Anaemia in pregnancy, characterized by a decrease in the oxygen-carrying capacity of the blood due to dysfunctional red blood cells (Prakash & Yadav, 2015;Fraser & Cooper, 2004) and haemoglobin concentration of less than 110g/l (World Health Organization, 2018) and or approximately a haematocrit of less than 33% (Auerbach & Landy, 2020) increases the risk of maternal morbidity during pregnancy. A study conducted by Lin et al (2018) revealed that pregnant women with lower family per capita presented with anaemia more than those with the higher one and that anaemia was prevalent in women who were from rural areas. Melku et, al (2014) also in their institutional based cross sectional study on the prevalence and predictors of maternal anemia during pregnancy revealed that mothers with low monthly family income were three times more likely to be aneamic as compared to those with high monthly income. Anaemia during pregnancy increases the risk of postpartum haemorrhage, one of the leading causes of maternal mortality in Botswana (Statistics Botswana, 2018). These nutrients related problems often result in fetal deaths, premature births, pregnancy loss, and maternal mortality morbidity and deformity (WHO, UNICEF, 2015). Poverty primarily generates adverse maternal outcomes by exposing women to exceedingly poor health conditions. Women's health is key to affect children's survival, household wellbeing, and societal continuity. Women who have not completed at least high school are at risk for poor health. (Gibbs & Engebretson, 2013). The greatest impact of malnutrition is mostly notable on the girl child. An undernourished growing girl child is at increased risk of developing stunted growth with a contracted pelvis. 2-15% of pregnancies are complicated by pelvic disproportion (Deepika et al, 2019). A contracted pelvis may interfere with progress of labour which may subsequently negatively affect her during childbirth process. The girl-child's role as caregiver also contributes to a large number of girls being absent from the natural science careers and being channeled into less-paying jobs (Tlou, 1999). This may result in high failure rates for girls, a phenomenon that exposes them to poverty and a low level of living. Education has an important influence on socioeconomic status. Early marriages of girl children are exacerbated by among other things the low socio-economic position, traditional beliefs and cultural obligations of many families in Botswana (Rivers, 2000). A related issue is that men generally own more resources than women. As such some men have a tendency of enticing young girls to have sexual intercourse with them in exchange for money