Archive for the ‘Health’ Category
“Women are not dying because of diseases we cannot treat. They are dying because societies have yet to make the decision that their lives are worth saving.” — Mahmoud Fathalla, Former President of the International Federation of Gynaecology and Obstetrics, 1997
Researchers at the World Health Organization have recently documented a substantial 48% decrease in the numbers of unsafe abortion deaths. In 2008, 47,000 women a year lost their lives from complications of unsafe abortion, compared to 70,000 in 2003. But the bad news is that unsafe abortions have not decreased and are still the predominant way that women end pregnancies in developing countries. Abortions appear to a bit less unsafe because more women are turning to safer medical abortion pills to induce their own abortion.
Unsafe abortion deaths are a direct consequence of antiquated and cruel laws against abortion. About 21.6 million unsafe abortions occurred worldwide in 2008, almost all in developing countries where abortion is illegal. (This compares to 19.7 million in 2003, with the rise due to the increasing number of women of childbearing age in the world.) Among women who survive unsafe abortion, an estimated 8.5 million suffer complications, with 1 in 4 needing medical attention.
In contrast, death from unsafe abortion has been virtually eliminated in western industrialized countries that have legalized abortion, and the complication rate is extremely low. When abortion is legalized in a country, there is typically a dramatic decline in maternal deaths and complications due to abortion. This pattern has been repeated numerous times since the 1950’s when abortion was first legalized in former Eastern Bloc countries.
Legal abortion saves women’s lives and improves their health because without it, women risk their safety by resorting to unsafe illegal abortion. The right to abortion also advances women’s equality, liberty, and other human rights, freeing women to pursue an education and career and to participate fully in public life. Access to abortion allows women to better plan and provide for their families, which benefits the entire community and society. Unplanned births of unwanted children can be very crippling to women and families, leading to higher rates of poverty and dysfunction, including child abuse. These factors make the provision of safe and legal abortion a vital public health interest that negates any justification for criminalizing the procedure.
Yet here we are, one decade into the 21st century, and almost every developing country in the world continues to enforce a near-total criminal ban on abortion. Abortion is illegal primarily in Africa, Latin America, and some parts of Asia, as well as a tiny handful of developed countries like Poland and Ireland. However, all countries with more liberal abortion laws still retain abortion as a criminal offence with exceptions, or have enacted further legal restrictions that make it difficult to access.
If the intent behind banning abortions is to stop or reduce them, it’s been a total failure. In 2007, the World Health Organization and the Guttmacher Institute found that overall abortion rates around the world are similar, regardless of whether or not abortion is illegal in a country. This is because countries with strict anti-abortion laws have well-developed black markets for abortion. The global average abortion rate for women of childbearing age (15-44) was 29 per 1,000 women in 2003, with the highest number of abortions occurring in countries where it’s highly restricted and in countries with poor access to contraception. Eastern Africa’s rate was 39 per 1,000 women, while South America’s rate was 33.
In countries with fewer restrictions where legal abortion is widely available, the rates are generally much lower, plus we see a decline in abortion rates as contraception use rises. Canada is the only democratic nation in the world with no abortion law or restrictions, but it has a low abortion rate of 14.1 abortions per 1,000 women of childbearing age. That compares favourably to western Europe’s rate of 12, the lowest abortion rate in the world and the region with the most liberal abortion laws. In contrast, the American rate is 19.4 (for 2005) and U.S. women must navigate through a thicket of abortion restrictions. There isn’t a shred of evidence that such restrictions are effective or helpful for women or society; instead, they create arbitrary obstacles and delays for women seeking abortion care.
Who should we blame for this global travesty of injustice and for the continuing suffering and deaths of women? The obvious culprits, of course, are the Vatican, conservative countries, various Catholic and fundamentalist religious organizations, and right-wing politicians. But perhaps a better question is: Why does the world allow these entities to inflict such a terrible toll on women’s lives and health, year after year? The most obvious culprit in this case would appear to be sexism and patriarchy, which are very much alive and well in our modern age, and still socially acceptable compared to racism. Traditional views on women’s motherhood role are the main reason that women’s rights and equality still lag far behind the rights of minorities and other vulnerable groups. Much of the world still clings to the deeply-held assumption that women’s dignity and humanity is tied to being a mother, even though this subordinates women to a biological function. Moreover, our male-dominated patriarchal societies still try to guarantee paternity by controlling women’s sexual and reproductive behaviour at the expense of their freedom and human rights.
The United Nations’ position on abortion reflects the world’s hostile attitude towards safe abortion as an essential part of women’s reproductive rights and the cornerstone of women’s health and survival. Although the UN’s purpose is in part to promote and encourage “respect for human rights and for fundamental freedoms for all without distinction as to race, sex, language, or religion,” the UN has essentially abandoned women who need abortions by caving to pressure from right-wing forces.
The World Health Organization (WHO) welcomed the relaxation of the Vatican’s stance against condom use.
Pope Benedict XVI said the use of condoms is acceptable to help prevent the spread of HIV and AIDS.
“The Pope’s statement is in line with evidence that condoms are highly effective in preventing infection with the HIV virus. If used correctly and consistently, the male condom is the most efficient protection against the sexual transmission of HIV and other sexually transmitted infections,” said WHO director for Western Pacific region Dr. Shin Young-soo.
Shin said the papal statement would help ease the reluctance of several sectors to use condoms. He acknowledged, however, that the pope was not endorsing the use of condoms as a means for birth control.
WHO records show that the prevalence of HIV in Asia Pacific had reached 20 percent among sex workers and up to 30 percent among men having sex with men.
“The truth is there for everyone to see. Unprotected sex is a central driver of the AIDS epidemic in Asia,” Shin said.
In a report of the Asia Commission on AIDS in 2008, it was estimated that some 75 million men in the region patronize sex from 10 million sex workers and, at the same time, have sex with 50 million regular or casual partners.
WHO had warned that in Western Pacific, HIV infection will continue to rise if countries will not focus on people with “risky lifestyles.”
WHO said 130,000 to 150,000 new infections related to high-risk lifestyle occur every year in the Western Pacific region.
These include infections through unprotected sex, sharing drug needles, and men having sex with men.
“While condom use remains the core strategy for preventing HIV and other sexually transmitted infections among sex workers, essential and affordable sexual and reproductive health services should also be made available to sex workers to address a host of other issues,” it said.
These services include voluntary HIV counseling and testing, STI diagnosis and treatment, cervical cancer prevention, prevention of parent-to-child transmission, contraception counseling, abortion and post-abortion care, as well as specialized support to the transgender community.
It is estimated that some 1.4 million people in Western Pacific were diagnosed with the AIDS virus. Ten years ago, the number of cases was 680,000.
Worldwide, some 33.4 million people are living with HIV.
House Minority Leader Edcel Lagman also welcomed the new papal statement on condom use, saying it supports his advocacy of family planning through the use of contraceptives.
“This is a very welcome development as it signals the liberalization of the stand of the Catholic Church when it comes to condom use to prevent the spread of HIV/AIDS,” said Lagman, principal author of the highly contested Reproductive Health (RH) Bill.“The moderation of the Church’s position on condoms to prevent the spread of a deadly disease may ultimately evolve to include the use of condoms and other contraceptives to prevent high risk pregnancies,” he added.
Lagman then said the use of contraceptives is a lesser evil than committing abortion and having increased incidents of maternal death. “Family planning and contraception save lives by helping women avoid high risk pregnancies which often end in maternal and infant death or morbidity,” he said. Citing data from the National Statistics Office, he said maternal deaths in the Philippines account for one out of every seven deaths of women of reproductive age. He noted that a study by the World Health Organization (WHO) and the United Nations Population Fund showed that one in three deaths related to pregnancy and childbirth could be prevented if women who want to use contraception are given access to it.
The study also showed that helping women plan their families can prevent one million infant and child deaths every year worldwide because closely spaced pregnancies threaten infant survival.
Lagman also cited another study showing that regular and proper use of contraceptives reduces the incidence of abortion by 85 percent.
“Clearly, a pregnancy that is planned and wanted will not be aborted. It is therefore only logical to conclude that the more women can avoid unintended and mistimed pregnancies through effective family planning, the less the incidence of abortion will be,” he said. Despite the endorsement from the Vatican, the Catholic Bishops’ Conference of the Philippines (CBCP) vows to continue opposing the RH bill “because that is our moral duty,” said Batangas Archbishop Ramon Arguelles, vice chair of the CBCB Episcopal Commission on Family and Life (ECFL). With Jess Diaz, Evelyn Macairan
We, undersigned, hereby express our concern about the situation in Hungary regarding non-hospital birth. It is shameful that Dr. Ágnes Geréb and other midwives providing responsible assistance to homebirthing families could become the victims of a show trial beneath the dignity of a democratic state.
We think that prosecuting midwives because of a regrettable case that could have happened in a hospital is unacceptable. The rate of neonatal mortality in Hungary for out-of-hospital birth is 1 out of a thousand, while 8 out of a thousand for hospital birth (international statistics are in line with the Hungarian data: in countries where assisted, planned out-of-hospital birth is regulated, maternal and neonatal mortality and morbidity rates of homebirth are better or at least as good as corresponding rates of hospital birth.)
Midwives in our country face several legal and professional problems due to the current lack of appropriate legislation, therefore their activity is not judged according to protocols developed and adopted by midwives, but according to the protocols of another and completely different approach, that of medicalized obstetrician paradigm. In this present unlawful situation not only families choosing homebirth are negatively discriminated, but also those dedicated professionals, who assist them as midwives.
The Hungarian Parliament failed to fulfill its constitutional obligation by not creating the legal, financial, institutional and educational framework for planned, assisted out-of-hospital birth. The legal deficiency subsists, and this outrageous situation cannot be justified by the fact that the College of Gynecologists and Obstetricians tenaciously stands against homebirth despite international recommendations, scientific evidence and the opinion of experienced professionals. Citizens of Hungary who would like to make responsible and free choices regarding the location and circumstances of their birth, find themselves is dishonoring situations, although the Constitution guarantees their right to self-sovereignty.
We request that competent authorities and professional bodies promote effective cooperation of parties, and reconcile this discreditable situation.
We also request that the Judiciary Administration fairly and impartially run the trial, staying away from the unlawful persecution of professional midwives assisting homebirth.
Sign the petition at http://www.petitiononline.com/szul2010/petition.html
A new Amnesty report launched in Jakarta on Thursday 4 November details the fatal consequences of denying access to sexual health services for women in Indonesia, the largest Muslim country in the world.
Left Without a Choice describes how government restrictions and discriminatory traditions threaten the lives of many Indonesian women and girls by putting reproductive health services out of their reach.
Amnesty International’s research shows discriminatory practices and problematic laws are prohibiting access to contraception for unmarried women and girls, and endorsing marriage for girls younger than 16. The law requires a woman to get her husband’s consent to access certain contraception methods, or an abortion even in the event that her life is at risk. Amnesty International also found that health workers frequently deny the full range of legally available contraceptive services to unmarried women and also to childless married women.
Salil Shetty, Amnesty International’s Secretary General, said:
“Restrictions on sexual and reproductive rights are placing severe and potentially deadly obstacles in the way many women and girls can access reproductive health information and services.
“Indonesia must do more to ensure that old stereotypes and mindsets are replaced with a more forward-looking recognition of the problems and needs facing their wives, sisters and daughters.”
Interviews with Indonesian women and girls, as well as health workers, highlighted how restrictions increase unwanted pregnancies and force many women and girls to marry young, drop out of school, or seek an illegal abortion. An estimated two million abortions are performed in Indonesia every year, many of them in unsafe conditions.
Indonesia’s Maternal Mortality Ratio (MMR) is amongst the highest in the East-Asia Pacific region.
At 228 per 100,000 live births, Indonesia’s MMR is overall at least four times higher than in neighbouring countries, such as China (56), Malaysia (41) and Thailand (44).
According to official government figures, unsafe abortions are responsible for between five and 11 per cent of maternal deaths in Indonesia.
A woman or girl seeking an abortion (the legal age for criminal responsibility in Indonesia is eight), or a health worker providing one, may be sentenced to up to four and 10 years’ imprisonment respectively
Domestic violence in Indonesia is a serious problem. In 2010, Indonesia’s National Commission on Violence against Women reported a 263 per cent increase in the number of reported cases (143,586 cases) of violence against women compared with the previous year (54,425 cases).
Part of a longer article at http://www.amnesty.org.uk/news_details.asp?NewsID=19068
See also: Abortion is about balancing rights – religious medics don’t get the final say
The religious rights of a small group of medical professionals do not trump those held by the remainder of the citizenry
Poor, rural, Quechua-speaking women in the Peruvian province of Anta who were victims of a forced sterilisation programme between 1996 and 2000 have filed a new lawsuit in their continuing struggle for justice.
In May 2009, Jaime Schwartz, the public prosecutor investigating the case against four former health ministers of the Alberto Fujimori administration (1990-2000), decided to shelve the investigation. He said the case involved alleged crimes against the victims’ life, body and health, and manslaughter, and that the statute of limitations had expired.
But the plaintiffs in the case had brought accusations of genocide and torture, which as crimes against humanity have no statute of limitation. The attorney-general’s office upheld Schwartz’s decision, overruling the complaint lodged against it by the victims and the human rights organisations providing them with legal advice.
Now the Women’s Association of Forced Sterilisation Victims of Anta, a mountainous province in the southern department of Cuzco, has decided to combat impunity with a new strategy: it is presenting a new lawsuit against those responsible for family planning policy in the last four years of the Fujimori regime.
The Association’s approximately 100 members are rural women whose testimonies have revealed the hidden side of the National Programme for Reproductive Health and Family Planning, imposed by coercion and deceit under the guise of an anti-poverty plan.
The study documented for the first time the systematic use of sterilisation practices that particularly targeted poor, indigenous, rural women.
As a result of the publication, Tamayo received threats from the government. She had to leave the country and went to live in Spain, but has now returned to Peru to advise the Anta Women’s Association on the new lawsuit.
The Peruvian state has admitted that 300,000 sterilisations were performed under the VSC programme. The ombudsman’s office has collected direct testimony from 2,074 women who were sterilised without their consent between 1996 and 2000.
In 2003, the Peruvian state signed a friendly settlement agreement before the Inter-American Commission on Human Rights (IACHR) in the case of Mamérita Mestanza, who died in 1998 as a result of a poorly performed tubal ligation procedure done without her consent.
The state acknowledged its responsibility, recognised the abuses committed under the family planning programme, undertook to investigate and bring to trial the government officials who devised and implemented the campaign, and promised to pay reparations to Mestanza’s family.
But the attorney-general’s office dragged its feet on the promised investigation, which made little progress before it was shelved by the public prosecutor in 2009. Meanwhile Alejandro Aguinaga, one of the accused, a former health minister and personal physician to Fujimori, was elected to Congress in 2006 and is now vice president of the legislature.
Fujimori is in prison for 25 years, convicted of several charges of corruption and human rights violations.
The state’s failure to carry out this part of the friendly agreement “is prolonging the pain of thousands of victims, because the accused are carrying on as respectable members of society when they really should be called to account in the courts,” said Tamayo, who is also a researcher for the Spanish chapter of the global rights watchdog Amnesty International.
“This time, those responsible for the forced sterilisation plan will be sued individually for crimes against humanity and torture,” she said.
Each of the accused will also be charged “for war crimes, because the coerced sterilisation was carried out in the context of the 1980-2000 armed conflict (between the military and leftwing guerrillas), when the armed forces were used to threaten and terrorise” the civilian population, Tamayo said.
Specifying international crimes (which include crimes against humanity, genocide, torture and war crimes) will allow “other countries to prosecute the accused, if the Peruvian state continues to protect them,” she said.
“The IACHR has already indicated that forced sterilisation is a matter of international law,” the rights activist said.
Tamayo said the lawsuit will be brought by the victims in Anta, because in that province “sterilisation was implemented door to door, the health authorities were given ‘quotas’ of sterilised women that they were required to meet, and all the victims belonged to the same indigenous ethnic group.”
This shows that “those who designed the programme defined its targets with abominable precision,” Tamayo said.
Part of a longer article at http://ipsnews.net/news.asp?idnews=53177
A global campaign that aims to save the lives of 16 million mothers and children over the next five years was being launched by U.N. Secretary-General Ban Ki-moon on Wednesday with as much as $40 billion in commitments from world governments and private aid groups.
The so-called Global Strategy for Women’s and Children’s Health was being announced at the end of a three-day summit to review efforts to implement anti-poverty goals adopted at a summit in 2000. These include cutting extreme poverty by half, ensuring universal primary education, halting and reversing the HIV/AIDS pandemic, and cutting child and maternal mortality.
“Women and children play a crucial role in development,” Ban said in a statement prepared for the event that was released by his office. “Investing in their health is not only the right thing to do — it also builds stable, peaceful and productive societies. “
Ban has made the reduction of maternal and child deaths a personal campaign, and it has been a key topic during the summit. Worldwide every year, an estimated 8 million children die before reaching their 5th birthday, and about 350,000 women die during pregnancy or childbirth.
Even before the details were announced, the international aid organization Oxfam expressed skepticism about how much money was truly new, and how the program would be administered and held accountable.
“That kind of money would go a long way toward reaching the child and maternal health goals, but we have a big concern,” said Oxfam spokeswoman Emma Seery. “Where will that money come from?
“Half of the donors cut their aid last year” amid the global economic crisis, she said. “We’re just nervous that it will be governments bringing together a lot of previous commitments, and that won’t mean much for poor people.”
U.S. Secretary of State Hillary Clinton was expected at the afternoon “Every Woman, Every Child” event, along with world leaders including Chinese Premier Wen Jiabao, Rwandan President Paul Kagame and the prime ministers of Ethiopia, Norway, and Tanzania. Melinda Gates of the Bill & Melinda Gates Foundation was also on the advance roster of speakers.
“When we first started talking about this five years ago, there didn’t seem to be any interest, very little commitment,” said Dr. Flavia Bustreo, a pediatrician who heads the World Health Organization’s Partnership for Maternal, Newborn and Child Health in Geneva, Switzerland.
“But with the help of many, and the leadership of the Secretary General, this week is like a dream come true,” said Bustreo, whose organization has worked with Ban’s office on the strategy in recent months.
WHO will chair the global strategy, with a progress report delivered annually to the U.N. General Assembly, she said.
Bustreo said some money could be used to pay for simple, inexpensive tools and practices that could save millions of the world’s children each year.
She said the 1 million newborns who die each year through aspiration — literally drowning from fluid in the breathing passage — could have been saved with a tool that has a bulb like a turkey baster that uses suction to clear away liquids.
The lives of older children can be saved with re-hydration liquids to combat diarrhea, immunizations for childhood diseases like measles, and vitamin supplements to fight malnutrition, she said.
Improving maternal health is more difficult — and costly. Bustreo said half of all maternal deaths are caused by complications of delivery, such as obstructive labor, that require surgery.
In 2000, the U.N. set “Millennium Development Goals” that included reducing child mortality by two-thirds and maternal mortality by three quarters by 2015.
Forensic Exams Should Respect Survivors’ Rights to Health, Privacy, and Dignity
Many Indian hospitals routinely subject rape survivors to forensic examinations that include the unscientific and degrading “finger” test, Human Rights Watch said in a report released today. It urged the Indian government to ban the practice, used to determine whether the rape survivor is “habituated” to sexual intercourse, as it reforms its laws on sexual violence.
The 54-page report, “Dignity on Trial: India’s Need for Sound Standards for Conducting and Interpreting Forensic Examinations of Rape Survivors” documents the continued use of the archaic practice and the continued reliance on the “results” by many defense counsel and courts. The practice, described in outdated medical jurisprudence textbooks used by many doctors, lawyers, and judges, involves a doctor inserting fingers in a rape victim’s vagina to determine the presence or absence of the hymen and the so-called “laxity” of the vagina. These findings perpetuate false and damaging stereotypes of rape survivors as “loose” women. Defense attorneys use the findings to challenge the credibility, character, and the lack of consent of the survivors.
“This test is yet another assault on a rape survivor, placing her at risk of further humiliation,” said Aruna Kashyap, women’s rights researcher at Human Rights Watch. “The Indian government should heed demands of Indian activists to abolish this degrading and useless practice.”
Finger test findings are scientifically baseless because an “old tear” of the hymen or variation of the “size” of the hymenal orifice can be due to reasons unrelated to sex. Carried out without informed consent, the test would constitute an assault, and is a form of inhuman and degrading treatment, Human Rights Watch said.
“I was so scared and nervous and praying all the time: ‘God, let this be over and let me get out of here fast,” the report quotes one rape survivor as saying as she described her experience of a forensic examination.
The Indian government amended its evidence law in 2003 to prohibit cross-examination of survivors based on their “general immoral character.” The Indian Supreme Court, whose decisions are binding, has described opinions based on the finger test as “hypothetical and opinionative,” and has ruled that they cannot be used against a rape survivor.
Although these developments have helped curtail the practice, the Indian government has yet to take steps to ensure that all states eliminate it. There are no nationwide guidelines or programs to standardize forensic examinations and to train and sensitize doctors, police, prosecutors, and judges to survivors’ rights. But the Indian government is currently reviewing laws regarding sexual violence, presenting a unique opportunity for change.
“The Indian government has paid little attention to how health care and forensic services are delivered to survivors of sexual violence,” Kashyap said. “The Indian government should set right this injustice with a comprehensive policy and program for such services.”
The report is based on 44 interviews in Mumbai and Delhi with activists, rape survivors and their parents, prosecutors, other lawyers, judges, doctors, and forensic experts. Research also included a review of forensic examination templates used in those cities, and an analysis of 153 High Court judgments on rape that referred to the finger test findings from 18 states. It finds that the finger test-related information continues to be collected and used.
Forensic examinations are a harrowing experience for many rape survivors, who are shunted from one hospital or ward to another for various aspects of the examination. Often doctors insist that the survivor must make a police complaint when she approaches them directly, which can intimidate her. Further, inserting fingers into the vaginal or anal orifice of an adult or child survivor of sexual violence during a forensic examination can cause additional trauma, as it not only mimics the abuse but can also be painful. Some doctors in India conduct the finger test with little or no regard for a survivor’s pain or trauma, Human Rights Watch found.
Many High Court judgments reveal that doctors have testified in court that having one or two fingers inserted into the vagina is “painful” or “very painful” for the survivor. And when the survivor did not experience any pain – if two fingers could be inserted “painlessly” or “easily” – then she was described as being “habituated to sex.”
“Survivors of sexual violence have the right to legal recourse without being further traumatized in the process,” Kashyap said. “The health and criminal justice systems should work together to ensure that they do not perpetuate damaging stereotypes of survivors.”
The Maharashtra and Delhi governments continue to recommend the finger test in their forensic examination templates. For example, as recently as June 2010, the Maharashtra state government introduced a standard forensic examination template that includes a series of questions about the hymen, including the number of fingers that can be admitted into the hymenal orifice.
Early this year, the Delhi government introduced a forensic examination template that asks questions about the hymen, including whether it is “intact” or “torn,” the “size of the hymenal orifice,” whether the vagina is “roomy” or “narrow” and has “old tears,” and even asks the examining doctor to give an opinion whether the survivor was “habituated to sex.” Much of the Delhi template resembles a template created by the Indian Medical Association and disseminated to doctors across the country between 2006 and 2008.
The World Health Organization’s (WHO) “Guidelines for medico-legal care for victims of sexual violence” recommends that health care and forensic services be provided at the same time, and by the same person, to reduce the potential for duplicating questions and further traumatizing the survivor of sexual assault. It states that health and welfare of a survivor of sexual violence is “the overriding priority” and that forensic services should not take precedence over health needs. It also says forensic examinations should be minimally invasive to the extent possible and that even a purely clinical procedure such as a bimanual examination (which also involves the insertion of two fingers into the vagina) is rarely medically necessary after sexual assault.
The Indian government should use its ongoing reform process for laws relating to sexual violence to prohibit the finger test and standardize the medical treatment and forensic examinations of survivors of sexual violence in line with the rights to health, privacy, dignity, and legal remedy, Human Rights Watch said. The government should introduce special programs to sensitize doctors, police, prosecutors, and judges to the rights of survivors, and set up multidisciplinary teams in every government hospital with doctors trained to be sensitive to survivors and with training and equipment to conduct forensic examinations in a manner that respects survivors’ rights.
Part of a longer press release at http://www.hrw.org/en/news/2010/09/06/india-prohibit-degrading-test-rape
Though the Indonesian government banned female genital mutilation/cutting (FGM/C) four years ago, experts say religious support for the practice is more fervent than ever, particularly in rural communities.
A lack of regulation since the ban makes it difficult to monitor, but medical practitioners say FGM/C remains commonplace for women of all ages in this emerging democracy of 240 million – the world’s largest Muslim nation.
Although not authorized by the Koran, the practice is growing in popularity. With increased urging of religious leaders, baby girls are now losing the top or part of their clitoris in the name of faith, sometimes in unsanitary rooms with tools as crude as scissors.
“We fear if [FGM/C] gets more outspoken support from religious leaders it will increase even more. We found in our latest research that not only female babies are being circumcised, but also older women ask for it,” said Artha Budi Susila Duarsa, a university researcher at Yarsi University in Jakarta.
While the procedure in Indonesia is not as severe as in parts of Africa and involves cutting less flesh, it still poses a serious health concern.
Indonesia forbade health officials from the practice in 2006 because they considered it a “useless” practice that “could potentially harm women’s health”.
However, the ban was quickly opposed by the Indonesian Ulema Council, the highest Islamic advisory body in Indonesia.
In March this year, the Nahdlatul Ulama (NU), the country’s largest Muslim organization, issued an edict supporting FGM/C, though a leading cleric told the NU’s estimated 40 million followers “not to cut too much”.
FGM/C traditionally existed as a sign of chastity; a symbolic practice performed by shamans, or local healers, who used crude methods such as rubbing and scraping.
With shamans largely falling out of favour, the religious are turning to midwives who rely more on cutting instead.
During the 32-year Suharto dictatorship, outspoken religious expression was discouraged, but since his fall in 1998, people started looking for their religious identity, with stricter interpretations of Islam being adopted by scores of municipalities.
More Indonesian Muslim women wear a headscarf now, claiming it is more accepted than it was 15 years ago.
The 2006 ban prohibited FGM/C, but in practice there is no oversight.
Yarsi University researchers found that in spite of the ban, the practice continues unabated in hospitals and health centres.
According to Yarsi University’s research, most incidents happen in secret, sometimes unhygienic, back-street operating rooms – creating a big risk of infection.
The demand for FGM/C makes it hard to control the practice, said Minister of Women’s Empowerment Linda Amalia Sari Gumelar.
Gumelar is working with the Ministry of Health to make an unsafe practice safer, even though it is outlawed and has been condemned by a large number of treaties and conventions, and ratified by most governments of countries where FGM/C is present.
The development dismays women’s rights fighter Anshor.
“I would advise not to circumcise your daughters at all,” Anshor said. “If women are circumcised, people believe they become more beautiful and not as wild and will make men more excited in bed. For women themselves, they don’t get any excitement at all.”
Part of a longer article at http://www.alertnet.org/thenews/newsdesk/IRIN/eb96b7a12a77556b16833ac9600fabe3.htm
In the north eastern Ethiopian region of Afar, more than 91 percent of women undergo one of the most severe forms of genital mutilation/cutting (FGM/C). Reproductive health education however, seems to be paying off, with the number of girls affected reducing, albeit gradually.
The eastern Somali region has the highest prevalence at 97.3 percent against 73.3 nationally, according to Ethiopia’s 2005 Demographic and Health Survey (EDHS).
In Afar, where the cut involves infibulation (or Type III FGM), the removal of the external genitalia, before sealing and leaving a small opening for menstrual blood, CARE Ethiopia is working with former traditional circumcisers to improve awareness of FGM-related effects. The women are trained in reproductive health education and equipped with skills to run alternative small businesses.
Aside from the immediate risks of severe blood loss, shock and infection, longer-term problems associated with FGM include: infections of the urinary and reproductive tracts, infertility and a range of obstetric complications, such as postpartum haemorrhage and death of the baby.
Interventions to enhance women’s and girls’ empowerment are aimed at helping address FGM/C.
FGM/C is among such preparations in a culture where the guarantee of a girl’s virginity is viewed as a prerequisite for an honourable marriage. The belief that FGM/C enhances a girl’s chances of finding a husband helps perpetuate the practice.
Besides being said to be hygienic and aesthetically pleasing, many communities also believe that women who are not cut are prone to break household goods. Taboos against uncircumcised women handling grain, serving food and drinks to elders put additional pressure, notes a report by the UN Children’s Fund.
“Where women are largely dependent on men, economic necessity can be a major determinant to undergo the procedure” adds the UN Population Fund (UNFPA). “FGM/FGC sometimes is a prerequisite for the right to inherit.”
UNICEF and UNFPA are also working to reduce FMG/C in Ethiopia.
Nine circumcisers were recently arrested in Afar, with seven being sentenced to between three and five years in jail, Amibara woreda women’s affairs office head, Fatuma Ali, told IRIN.
“These circumcisers were caught red- handed by the community itself,” said Ali. “The anti-FGM/C law [passed in 2004] helped us a lot in the fight against FGM/C. But we don’t see the enforcement of the law as the only option. We are also working with the empowerment of traditional birth attendants, school boys and girls, as a key to eradicate FGM/C from our region.”
In Afar, the FGM prevalence has decreased by 7.5 percent since 1998, said a 2008 survey by the Ethiopia Goji Limadawi Dirgitoch Aswogaj Mehber, former National Committee on Traditional Harmful Practices. (Some agencies have challenged the methodology of this survey).
“We have to educate pastoral women in Afar and Somali. We have to create alternative sources of income for the women so that when they are empowered they will start to question the tradition that is against their life,” Netsanet Asfaw, the government whip, said at the meeting organized by anti-FGM/C advocate, the Somali model Waris Dirie.
Afar has registered at least 2,000 girls as free from circumcision in the past three years, according to CARE Ethiopia and Regional Women’s Affairs Office estimates. This is the highest number so far.
Studies revealed that in 2005, out of 15,000 women surveyed across Ethiopia, only 25.5 percent still supported FGM/C, down from 60 percent five years before, said UNICEF. “As FGM/C is deeply ingrained in the social fabric… any increase in opposition, even a small one, represents a significant indication of change” it noted.
Among the reasons for this is higher educational attainment among women, anti-FGM laws, social support and awareness-raising.
Access to education and control of economic resources would also “enable women to realize the full extent of their rights and may help them conclude that the practice of FGM/C can end”, said UNICEF.
Earning an income is helping women to speak up. “We have never talked to a man like this, we are now discussing equally with men as we save our own money,” Use, who, with 14 other women, formed a group that runs a small shop, told IRIN.
Part of a longer article at http://www.alertnet.org/thenews/newsdesk/IRIN/746697c64ba4fe60b5da742ff6658852.htm
A growing number of women in South Africa and other countries in the region have come forward in the last few years with stories of forced or coerced sterilization after an HIV-positive test result.
Local rights groups in Namibia, with the support of the International Community of Women Living with HIV/AIDS, have helped uncover 15 such cases, and a trial involving three HV-positive women who say they were sterilized at public health facilities without their consent is due to resume on 1 September in the High Court.
“It does appear that in Namibia [the practice of sterilising HIV-positive women] has been fairly widespread and systemic,” said Delme Cupido, coordinator of HIV/AIDS policy at the Open Society Institute of Southern Africa (OSISA), which is providing funding for the legal action.
Similar cases have been uncovered in Zambia, and Promise Mtembu, an AIDS and women’s rights activist who was herself sterilized in 1997, is gathering stories from South African women living with HIV whose reproductive rights have been violated.
Some of the 12 cases she has so far documented occurred several years before prevention of mother-to-child transmission (PMTCT) services were available, but the most recent took place in 2009, by which time public health facilities were using a dual-antiretroviral therapy regimen that can reduce the risk of mother-to-child HIV transmission to less than five percent.
Aside from the availability of PMTCT, performing a medical procedure without informed consent is a serious human rights violation and yet, according to Mushahida Adhikari, an attorney at the Women’s Legal Centre in Cape Town working with Mtembu to compile cases with a view to taking legal action, “A lot of women didn’t know it was wrong that they’d been sterilized. In many cases [the women] knew what they were signing, but didn’t feel like they had a choice.”
Mtembu and Adhikari hope to collect enough strong cases to take to South Africa’s High Court and, in the event of a ruling in their favour, to present them to the country’s Constitutional Court, but “It’s going to be a long, hard slog,” Adhikari warned. “A lot of the women don’t necessarily want to be part of a big class action, they just want an apology.”
Often the women do not want to go to court because they have not told their families about being sterilized. Adhikari said the stigma associated with not being able to have children could be as strong as being HIV positive.
Reversal may be possible, depending on how the sterilization was performed, but the procedure is difficult and too expensive for most of the women.
Part of a longer article at http://www.alertnet.org/thenews/newsdesk/IRIN/1847b302fcc73a35d9e924154abc71c2.htm
Slack Implementation and Lack of Oversight Causes Suffering and Death
Thousands of women and girls in Argentina suffer needlessly every year because of negligent or abusive reproductive health care, Human Rights Watch said in a report released earlier this week.
The 53-page report, “Illusions of Care: Lack of Accountability for Reproductive Rights in Argentina“, documents the many obstacles women and girls face in getting the reproductive health care services to which they are entitled, such as contraception, voluntary sterilization procedures, and abortion after rape. The most common barriers to care include long delays in providing services, unnecessary referrals to other clinics, demands for spousal permission contrary to law, financial barriers, and in some cases outright denial of care. http://www.hrw.org/node/92124
“Women need dependable care throughout their reproductive lives,” said Jose Miguel Vivanco, Americas director at Human Rights Watch. “But in Argentina, it’s more like a lottery: you might be lucky enough to get decent care but you are more likely to be stuck with deficient – or even abusive – services.”
As a direct result of these barriers, women and girls in Argentina often cannot make independent decisions about their health, and many face unwanted or unhealthy pregnancies as a result. Forty percent of pregnancies in Argentina end in abortions, which are often unsafe. Unsafe abortion has been the leading cause of maternal mortality in the country for decades.
The report identifies a lack of oversight and accountability for carrying out existing laws and policies as the main problems in the persistent denial of proper care. Doctors and other medical personnel who deny women services to which they are entitled, or who apply arbitrary conditions for receiving the services, rarely – if ever – are investigated or penalized.
“Argentina’s reproductive health policies are certainly not perfect, but if they were implemented they would prevent quite a lot of the suffering I saw in researching for this report,” Vivanco said. “The government needs to put a lot more effort into monitoring how these policies are carried out and punishing abuse.”
Human Rights Watch’s report also criticizes Argentina’s reproductive health policies for ignoring key constituencies such as women and girls with disabilities. With its recent ratification of the Convention on the Rights of Persons with Disabilities, Argentina has taken on specific international obligations in this area that are not being met, Human Rights Watch said.
“Women and girls with disabilities face all the same barriers as women without disabilities, and then some,” Vivanco said. “Apart from straight-up access issues - are there ramps at clinics, or is information translated into Braille or sign language, for example - there is a larger question of prejudice. Some doctors just don’t think women with visual or hearing disabilities, have sexual relationships or can remember to take their contraception.”
The Argentine government has recently taken steps to remedy some of the issues highlighted in “Illusions of Care,” though some of the policy changes were later retracted. In May, the National Health Ministry created a free call-in number to answer questions about where to find reproductive health care services and register complaints. In July, the ministry announced its intention to make sure that abortions are carried out for women and girls whose lives or health are threatened by their pregnancies, or who have been raped. The day after the announcement, however, the government retracted its statements, noting that it did not intend to guarantee access after all.
“The Argentine government seems to be slowly waking up to the notion that laws on reproductive health mean nothing unless they are enforced,” Vivanco said. “But unless changes are constant and clear, women and girls will continue to suffer and, in some cases, die.”
Women in Afghanistan suffer “extremely high rates of domestic violence” which include forced marriages and physical attacks, Afghan and United Nations officials announced one week after a report by a top Afghan health advisor revealed that suicide among Afghan women had increased about 20 times since the 1970s.
Nearly 2,000 cases of violence against women were reported between October 2006 and mid-2009, according to an updated Violence against Women Primary Database Report launched on Thursday by the Afghan Ministry of Women’s Affairs (MoWA) and the United Nations Development Fund for Women (UNIFEM), with support from the UN Assistance Mission in Afghanistan (UNAMA) and the Afghanistan Information Management System (AIMS).
The database includes information on incidences of physical attacks and emotional abuse, rape and kidnapping, forced sexual intercourse by a husband, polygamy, forced engagement and forced marriage, and restricted mobility and curtailment of women’s participation in public life.
Of the reported cases, nearly a quarter showed that women had temporary physical injuries; in more than 20 per cent of the cases, the woman ran away and 2.5 per cent of the cases resulted in death or attempted suicide.
Approximately 40 per cent of the reported cases in the database showed that no follow up was done and the outcome of the violence was “unknown.”
Among the recommendations, the authors of the report based on the database findings called for “zero tolerance” of men in positions of power who mistreat or abuse women, particularly those in police and military who are approached for assistance by women already victimized.
Speaking at the report launch, MoWA Acting Minister Dr Husn Banu Ghazanfar and UNIFEM Country Director Christine Ouellette praised the revised database and the resulting report.
“The availability of this database…in addition to the special emphasis given to gender equality and empowerment of women during the recently held Kabul Conference, are testimony to the concerted efforts of the Government and other stakeholders to address violence against women,” Ouellette said, noting the 20 July conference where the Government of Afghanistan launched a series of national priorities and programmes in the areas of security, governance, social and economic development and better service delivery to citizens.
The launch of the revised violence against women database comes one week after a report authored by a health affairs advisor for President Hamid Karzai revealed that suicide among Afghan women had increased by some 20 times over the past 40 years, counter to the international suicide rates which have remained stable.
“Evidence suggests an increasing trend of suicide in Afghanistan, especially among women, and using the method of self-immolation,” Faizullah Kakar wrote in The Elevated Prevalence of Depression and Risk of Suicide among Afghan Women.
Nearly one-third of Afghan women between 15 and 35 years of age suffer from depression and psychological problems, Kakar said.
He blamed “war-related stress, displacement stress, repatriation stress, insecurity and addictions to hashish and opium,” as well as a culture of traditional marriage.
“For these women, social stresses such as forced marriages turn into the proverbial ‘straw that broke the camel’s back,’” Kakar concluded.
Among his recommendations to the Government of Afghanistan to counter this trend is an “effective and coherent national strategy” which provides social support to high-risk individuals.
Tens of thousands of Kenyan women and girls suffer from obstetric fistula, a childbirth injury causing leakage of urine and feces, a direct result of inadequate health services and failed government policies, Human Rights Watch said in a report released earlier this month.
The 82-page report, “‘I Am Not Dead, But I Am Not Living’: Barriers to Fistula Prevention and Treatment in Kenya,” describes the devastating condition facing women with fistula in Kenya and the wide gap between government’s policies to address reproductive health and the reality of women’s daily lives. It documents health system failures in five areas: education and information on reproductive and maternal health; school-based sex education; access to emergency obstetric care, including referral and transport systems; affordable maternity care and fistula repair; and health system accountability. It also documents stigma and violence many fistula sufferers face.
“Many women and girls with fistula endure lives of shame, misery, violence, and poverty,” said Agnes Odhiambo, Africa women’s rights researcher at Human Rights Watch. “Preventing fistula and restoring women’s health and dignity requires more than good policies on paper. Kenya needs to keep its promise of decent health care for all.”
The risk of obstetric fistula often begins when young girls get pregnant or marry early, before their bodies are safely able to sustain a pregnancy. This can result in obstructed labor, and if emergency care – often a Caesarean section – is not accessible, the long labor results in destruction of vaginal tissue and causes a hole – a fistula – and incontinence. One of the factors leading to early pregnancy and childbearing is the lack of accurate information about sexuality. Human Rights Watch interviewed many girls with virtually no knowledge about reproductive processes or health.
Kwamboka W., who got pregnant at 13 while in primary school, told Human Rights Watch: “I didn’t know anything about family planning or condoms. I just went once and got pregnant. I still have no idea about contraceptives.”
Others told Human Rights Watch they had unprotected sex but thought they would not get pregnant because it was their first time or because they had irregular menstrual periods.
The report is based on field research conducted by Human Rights Watch in November and December 2009 in hospitals in Kisumu, Nairobi, Kisii, and Machakos, as well as in Dadaab in March 2010. Researchers interviewed 55 women and girls ranging in age from 14 to 73, 53 of whom had fistula. Twelve of those with fistula were between the ages of 14 and 18. Human Rights Watch also interviewed obstetric fistula surgeons, nurses working in hospital fistula wards, hospital administrators, representatives of nongovernmental organizations working on health and women’s rights, government officials, representatives of professional associations for doctors and nurses, international donors, United Nations representatives, and primary and secondary school teachers.
Kwamboka W. described her life after she developed a fistula: “I thought I should kill myself. You can’t walk with people. They laugh at you. You can’t travel; you are constantly in pain. It is so uncomfortable when you sleep. You go near people and they say urine smells, and they are looking directly at you and talking in low tones. It hurt so much I thought I should die. You can’t work because you are in pain; you are always wet and washing clothes. Your work is just washing pieces of rugs.”
Human Rights Watch found that even though the government has introduced sex education in schools, teachers often don’t take the time to teach it because it is not part of the syllabus.
The report also said that health care user fees are a significant barrier to maternity care and fistula surgery. Many of the women who suffer from fistula are poor. Women told Human Rights Watch how difficult it was to raise money for surgery. The Kenya government made a great stride when it began offering free maternity care in dispensaries and health centers, Human Rights Watch said. But this does not help the women who develop complications requiring care in hospitals, where fees are still charged. These fees deter poor women from seeking skilled maternity care.
Government hospitals are supposed to offer fee waivers for indigent patients, but the report identified critical shortcomings in the waiver process. These include lack of awareness of the policy among patients and some health providers; the reluctance of some facilities to publicize the waivers and deliberate withholding of information requested by patients; vague implementation guidelines, including the criteria for determining a patient’s financial needs; and lack of oversight and monitoring to ensure that hospitals grant waivers to qualifying patients. None of the women and girls interviewed by Human Rights Watch had received a waiver.
“Poor, rural, and illiterate women and girls are often the ones who develop obstetric fistula or die during pregnancy and childbirth,” Odhiambo said. “Important information and services are not reaching them, and this shows that government policies that promise health care equality are not being carried out.”
Strengthening health system accountability – giving people accessible and effective ways to provide feedback and lodge complaints, and ensuring that the feedback leads to improvements – can greatly enhance the health system, Human Rights Watch said. The current system of suggestion boxes is ineffective, especially for illiterate women, the report found. Several women and girls interviewed by Human Rights Watch had experienced abuse in health facilities, yet did not lodge complaints because they did not know how or feared retaliation.
“Camps” funded by international donors a few weeks a year in a number of towns offer surgical repairs to a small percentage of fistula sufferers, but even those who have successful surgery may still face stigma in their families and communities.
After years, sometimes decades, of isolation, many women and girls need help reintegrating into their communities. They need social and psychological support to regain self-esteem and confidence, to encourage participation in social and religious life, to regain fertility and an opportunity for a normal sexual life, and to ensure future safe childbirth. These women also need help to become financially self-sufficient.
The Kenyan government should develop and implement a national strategy to prevent fistula and provide needed services to those who have the injury, Human Rights Watch said. The effort should include a public awareness campaign about the causes of fistula, the need for childbirth to take place in properly equipped facilities, and the availability of treatment. The government should make comprehensive sex education part of the school syllabus to ensure that teachers allocate time to teach it.
The government also urgently needs to improve access to fistula surgery by subsidizing routine repairs in hospitals and providing free surgery for indigent patients, Human Rights Watch said. It should expand the exemptions from user fees to include all maternal health care, not just childbirth in dispensaries and health centers, and the government should urgently improve the quality of and access to emergency obstetric care.
Download the report from “I Am Not Dead, But I Am Not Living” – Barriers to Fistula Prevention and Treatment in Kenya from http://www.hrw.org/node/91514
Unsafe abortions account for more than one in 10 women who die in pregnancy in Ghana, according to new research by the US-based Guttmacher Institute, with ignorance of the law and inadequate facilities partly to blame, say health authorities. See http://www.guttmacher.org/pubs/IB-Abortion-in-Ghana.pdf
Abortion was declared legal in 1985 for women who have been raped, in cases of incest, or where the pregnancy will cause the mother physical or mental harm, but decades on, only 4 percent of women are aware of the law, according to 2009 government health statistics (based on 2007 data).
Over half of healthcare providers at a teaching hospital in Kumasi, south-central Ghana, were unaware that forms of abortion are legal in Ghana, and in localized assessments “many groups working in women’s reproductive health did not know either,” said senior Guttmacher Institute researcher Gilda Sedgh.
Some 15 percent of women and girls in Ghana have had an abortion, with rates highest for those living in urban areas. Most say they do so because they cannot afford to raise a child, according to studies.
While the majority sought a doctor, 43 percent turned to a pharmacist, friend, or traditional midwives to induce an abortion, with the result that 13 percent experienced a health problem following the procedure, and of them 41 percent received no medical care.
One in 45 women or girls in Ghana risks dying from pregnancy-related causes in their reproductive lifetime, according to the UN Children’s Fund (UNICEF).
While the government has to some degree been clear about its stance on abortion, “making people aware of the law is a slow process,” Sedgh told IRIN. “The stigma takes a long time to wane.”
But Gloria Quansah Asare, family health director in the Ghana Health Service, told IRIN the government must be cautious in promoting abortion services because there are not enough of them: “We don’t go to the public and announce ‘come for services’. If you do that and the people come and you can’t get the services, you will be in trouble.”
The health service does not have enough doctors or clinics that can offer comprehensive abortion care, says Asare. By this she means care that includes post-abortion training in family planning, provision of contraception and counselling, on top of the procedure. “But we have doctors who should be able to further train to perform abortions,” she told IRIN.
Some NGOs like Marie Stopes International, which is registered to provide abortions in Ghana, help fill the capacity gap.
Instead of promoting abortion services, the health authorities stress the dangers of unsafe abortion and no family planning. “We want to tell our public about the dangers of unsafe abortion… We say don’t go to someone who is untrained, but go to a recognized one [doctor]… We want people to practice family planning, so we talk about it.”
The health service and Ministry of Health have imposed minimum standards in government hospitals, so that all health workers involved are well-trained, will provide counselling and preserve women’s dignity in the care they provide.
This kind of comprehensive care is not yet available in all hospitals or in many private clinics, said Asare. Many doctors still perform abortions with no discussion of family planning or follow-up care: “The next time they [the patient] gets pregnant, she comes again. It is wrong.” But take-up is increasing, she and the Guttmacher Institute agree.
The government is running a “life choice” campaign to try to encourage more responsible family planning – billboards across towns, and radio spots, transmit the message. “Everybody talks about family planning… Even the Catholic Church, which doesn’t like contraceptives, promotes natural family planning,” Asare said.
More contraceptive advice and materials are needed in clinics and hospitals, says the Guttmacher Institute. Some 35 percent of married women in Ghana have an unmet need for contraceptives, according to the 2008 demographic health survey.
Getting the family planning message across should be easier than pushing the availability of safe abortions, as “nobody likes abortion [in Ghana] – society, health professionals, even patients, but people are dying from unsafe abortion,” Asare told IRIN. “We did a study and found even health workers are unwilling to perform abortions… so we have to roll it out in such a way that people will accept it,” she said.
Many law-enforcers do not agree with the law, and crack down on clinics despite the fact they are providing legal services, Sedgh told IRIN.
Some providers still impose stiff fees because they know the women coming to them are in a bind, says Sedgh. Women in Accra pay anything from $9 to $90 for an abortion in a hospital or private clinic, according to a 2002 study by US doctors.
Asare takes a practical approach. “If a doctor does not want to perform the abortion, he should be able to refer a patient to a place where they can get such a service.”
There are signs that views are changing. In one study in the capital Accra, most adolescent females interviewed said though they disapproved of abortion, they could describe situations – such as being in an unstable relationship, or not having enough money to raise a child – where they considered it acceptable.
And 80 percent of doctors at an Accra teaching hospital favoured establishing safe abortion units within hospitals.
The G8 and G20 Summits wrapped up after a tumultuous weekend. The protestors clashing with police got all the press but there were important developments for maternal and child health, HIV/AIDS and reproductive health as well.
The G8 released the details of its Muskoka Initiative for Maternal and Child Health on Saturday, a five-year, $7.3 billion package for improving maternal, newborn and child health and increasing access to reproductive health. The G8 countries have pledged US $5 billion of new money over the next 5 years and an additional $2.3 billion has been committed by non-G8 member states and foundations including the Netherlands, Norway, New Zealand, South Korea, Spain, Switzerland, the Gates Foundation and the United Nations Foundation. The communiqué notes that the G8 countries “fully expect” to mobilize more than $10 billion between 2010 and 2015 but doesn’t provide details on where that extra money might come from.
The G8 members call this “a comprehensive and integrated approach to accelerate progress towards MDGs 4 and 5 that will significantly reduce the number of maternal, newborn and under five child deaths in developing countries.” The G8 is working with partners to achieve the Millennium Development Goals (MDGs) by 2015 with a particular focus on MDGs 4 (Reduce by two-thirds the under-5 mortality rate by 2015) and MDG 5 (Reduce by three-quarters the maternal mortality ratio by AND achieve, by 2015, universal access to reproductive health). MDG 5 is farthest away from being achieved by 2015 and estimates are that another $20 billion is needed if we hope to reach those targets for reduction in maternal and child mortality and reproductive health access in time. The Muskoka Initiative doesn’t come close to meeting that $20 billion shortfall, but it is a start.
While the funds committed may not have been all we hoped for, there were some pleasant surprises in the communiqué details. The funds will support strengthened country-led national health systems in developing countries and will help them to deliver key interventions along the continuum of care from pre-pregnancy, to pregnancy, to childbirth, to infancy and early childhood. The funds can specifically be used for programs on pre-natal care; attended childbirth; postpartum care; sexual and reproductive health care and services, including voluntary family planning; health education; treatment and prevention of diseases including infectious diseases; prevention of mother-to-child transmission of HIV; immunizations; basic nutrition and relevant actions in the field of safe drinking water and sanitation. The communiqué for the first time ever commits G8 countries to “promote integration of HIV and sexual and reproductive health, rights and services within the broader context of strengthening health systems.” The mere inclusion of the phrase “sexual and reproductive health and rights” in a G8 communiqué seems like cause for celebration to me!
The G8’s recognition that there’s a need for money for a range of critical, complementary interventions is important as well. As the Partnership for Maternal, Newborn and Child Health points out in its statement on the G8, “hemorrhage is the biggest reason why women die after delivery, but with HIV at the root of 20 percent of maternal deaths globally — and higher in Africa — it is clear that we must take a wider view of health, as women themselves do.” The communiqué also included a commitment to work towards universal access to prevention, treatment, care and support for HIV and AIDS and to continue to support funding the Global Fund to Fight AIDS, TB and Malaria. G8 governments also express support for strengthening health information systems and sharing of innovations such as using mobile phones to provide health information and task shifting to make better use of scarce health workers.
Notably missing from the communiqué, not surprisingly, was any mention of abortion. Protestors on the streets of Toronto were seen carrying a banner that read, “Maternal health includes abortion!” but this fact was not recognized anywhere in the Muskoka Initiative. Unsafe abortions account for 13 percent of all maternal deaths worldwide and complications from the 19.7 million unsafe abortions performed annually are a serious public health threat. The communiqué addresses sexual and reproductive health care and services, but fails to recognize that safe abortion, when and here legal, is a critical piece of women’s healthcare access.
As the Summits concluded, new voices were added to the call for continued support for maternal and child health including the crucial voices of youth and developing country governments (with a rock star thrown in for good measure). The delegates to the official international youth summit being held concurrently with the G-8 and G-20 summits issued a statement calling on G8 leaders to “move quickly in creating a long-term maternal and child health plan for developing countries,” and identified lack of specialist training in the developing world surrounding prenatal and newborn care, and access to essential obstetric expertise as causes they would like to see the G8 take up.
Leaders from Algeria, Ethiopia, Malawi (Chair of the African Union), Nigeria, Senegal and South Africa were invited to meet with the G8 in a special afternoon session to discuss maternal and child health, highlighting the important role of developing countries themselves in this process. The communiqué indicates that, “G8 and African leaders recognize that the attainment of the MDGs is a shared responsibility and that strategies based on mutual accountability are essential going forward.”
African Union countries have already committed to devoting 15 percent of their budgets to health and we hope that this new working relationship with the G8 will signal willingness to meet and exceed those commitments. At the G20 Summit, leaders of the world’s 20 largest economies also recognized the role that all governments, including developing country governments, must play in supporting maternal and child health initiatives. While it was disappointing that the G20 did not specifically mention the Muskoka Initiative, it did announce that it is forming a Working Group to examine how it can play a greater role in development issues-a step in the right direction.
Not be outdone, Bono, U2 lead singer and co-founder of ONE, issued a statement saying that:
Prime Minister Harper’s plan for the G8 on maternal mortality is not everything that’s needed to tackle the moral affront of millions of mothers dying in childbirth, but it is a start on a job that world leaders need to finish when they gather at the UN in September for a special session on the Millennium Development Goals.
So what can be achieved with the money and the political commitments that we did manage to get from the G8 and G20? The communiqué says that this funding will help developing countries to prevent 1.3 million deaths of children under the age of five, prevent 64,000 maternal deaths, and enable access to modern methods of family planning by an additional 12 million couples.
Along with the G8’s stated new focus on accountability, the funding targets and promises to monitor progress towards achieving reductions in maternal and child mortality and expanded access to reproductive health services will also give advocates specifics that we can hold the G8 accountable for. Finally, as we move towards the September 2010 UN High-Level Plenary Meeting on the MDGs where governments will be asked to make additional renewed commitments to achieve the MDGs by 2015, this focus on maternal and child health is important. The Secretary General of the UN has launched a Joint Action Plan to Improve the Health of Women and Children, and advocates are pressing for the serious financial and political commitments that will be needed to achieve the goals.
The G8 and G20 have helped put maternal and child health on the map at this critical time. But awareness raising and promises are not enough. The protestors on the streets were yelling, “Whose streets? Our streets!” We must take up the call, “Whose lives? Women’s lives!” No woman should have to die giving life. We know what to do to improve maternal and child health. The governments of the G8 and G20 put themselves forward as the richest and most powerful leaders in the world. But that leadership won’t mean anything if they won’t commit to saving women and children’s lives.
The Muskoka Initiative, formally announced Friday, has largely failed to inspire both at home and abroad. Despite the $2.85-billion, five-year commitment of Canadian taxpayer money, the initiative is high on rhetoric but short on detail.
Buzzwords — like voluntary family planning, country ownership, health workers, information systems, continuum of care, accountability and effectiveness — are abundant. But the details are missing. How will the initiative be co-ordinated with existing global health activities, particularly the Global Fund? Will the initiative promote universal access to health care for women and children, and if so, how will this be financed? While named in the communiqué, it is not clear how the initiative fits in with the Millennium Development Goals (MDGs) as well as the UN Joint Action Plan for Women’s and Children’s Health.
The G8 communiqué claims the initiative will prevent the deaths of 1.3 million children five years and under and 64,000 maternal deaths while enabling 12 million couples to access family planning. Yet no information is provided on how these goals will be achieved. Perhaps this lack of specificity is the reason that matching contributions from other G8 countries were disappointingly low. A request for billions of dollars is normally accompanied by a strategic plan.
The lack of enthusiasm abroad is met with skepticism at home. This government recently cut funds to organizations working for the rights of women in Canada and abroad. It also decimated Status of Women Canada, and shut down gender equality units at the Department of Foreign Affairs and the Canadian International Development Agency (CIDA).
If Prime Minister Stephen Harper wants Canada to contribute to reducing maternal mortality, he must recognize that maternal health is not a one-off, stand-alone issue.
Improving maternal health depends on the protection, promotion and advancement of the rights and freedoms of women and girls. Canada needs to push countries to fully respect these rights and support programs at home and abroad that allow women and girls to realize them.
Such rights include the ability to access affordable, appropriate and effective health care, as well as the right to clean water and sanitation. Women have a right to be educated, deserve equal opportunities for employment and credit, as well as protection of their property and inheritance rights. The right of women to mobilize as members of civil society and to seek political office must be supported. Voluntary family planning is only voluntary if women’s rights are respected and if they have choice. To quote from the Beijing Platform, women must “have control over and decide freely and responsibly on matters related to their sexuality, including sexual and reproductive health, free of coercion, discrimination and violence.”
The Muskoka Initiative also needs to be closely linked to Canadian engagement in broader global health initiatives. In advance of the UN’s September MDG Summit, experts are debating how to generate more resources while ensuring that global health interventions are better co-ordinated and managed at the country level. Despite its G8 focus on maternal health, Canada has been largely silent on these debates, nor are they reflected in the G8 communiqué.
This silence is not new. Canada’s response to global health challenges has been largely reactive, driven by public policy issues such as the threat of H1N1, or by international processes at the World Health Organization and other multilateral agencies. This policy vacuum is accompanied by institutional fragmentation. Global health responsibilities are dispersed among CIDA, Health Canada, and the Public Health Agency of Canada. CIDA does not even list health as one of its three priorities, while Health Canada has few resources for international programming.
Canada, with its expertise in public health and its experience delivering universal health care to a dispersed and diverse population, should be a natural leader in global health. To realize this leadership potential, the government should articulate a bold Global Health Strategy — like the U.S. and British strategies — that identifies how Canada’s global health engagement will protect and improve the health of Canadians and of people around the world. This vision would articulate how best to marshal Canadian government, civil society and academic resources, and clearly delineate institutional responsibilities to implement global health initiatives.
Harper can take this opportunity to frame the maternal health initiative as a key component of Canada’s larger engagement on global health, and accompany the initiative by championing the rights of women and girls. Doing so will not only allay the cynics, it will provide a more inspirational, successful and sustainable foundation for the Muskoka Maternal Health Initiative.
Kurdistan Regional Government Should Outlaw the Practice
A significant number of girls and women in Iraqi Kurdistan suffer female genital mutilation (FGM) and its destructive after-effects, Human Rights Watch said today in a new report. The Kurdistan Regional Government should take immediate action to end FGM and develop a long term plan for its eradication, including passing a law to ban the practice, Human Rights Watch said.
The 73-page report, “‘They Took Me and Told Me Nothing’: Female Genital Mutilation in Iraqi Kurdistan” (download from http://www.hrw.org/en/reports/2010/06/16/they-took-me-and-told-me-nothing-0 ) documents the experiences of young girls and women who undergo FGM against a backdrop of conflicting messages from some religious leaders and healthcare professionals about the practice’s legitimacy and safety. The report describes the pain and fear that girls and young women experience when they are cut, and the terrible toll that it takes on their physical and emotional health. It says the regional government has been unwilling to prohibit FGM, despite its readiness to address other forms of gender-based violence, including domestic violence and so-called honor killings.
“FGM violates women’s and children’s rights, including their rights to life, health, and bodily integrity,” said Nadya Khalife, Middle East women’s rights researcher at Human Rights Watch. “It’s time for the regional government to step up to the plate and take concrete actions to eliminate this harmful practice because it simply won’t go away on its own.”
Human Rights Watch researchers conducted interviews during May and June 2009, with 31 girls and women in four villages of northern Iraq and in the town of Halabja. Researchers also interviewed Muslim clerics, midwives, healthcare workers, and government officials. Local nongovernmental organizations say that FGM may also be practiced among other communities in the rest of Iraq, but there are no data on its prevalence outside the Kurdish region.
The prevalence of FGM in Iraqi Kurdistan is not fully known as the government does not routinely collect information on the practice. However, research conducted by local organizations indicates that the practice is widespread and affects a significant number of girls and women.
The evidence obtained by Human Rights Watch suggests that for many girls and women in Iraqi Kurdistan, FGM is an unavoidable procedure that they undergo sometimes between the ages of 3 and 12. In some cases documented by Human Rights Watch, societal pressures also led adult women to undergo the procedure, sometimes as a precondition of marriage.
Human Rights Watch met Gola, a 17-year-old student from the village of Plangan. Gola told Human Rights Watch, “I remember my mother and her sister-in-law took us two girls, and there were four other girls. We went to Sarkapkan for the procedure. They put us in the bathroom, held our legs open, and cut something. They did it one by one with no anesthetics. I was afraid, but endured the pain. I have lots of pain in this specific area they cut when I menstruate.”
Young girls and women described how their mothers had taken them to the home of the village midwife, a non-licensed practitioner. They were almost never told in advance what was going to happen to them. When they arrived, the midwife, sometimes with the help of the mother, spread the girl’s legs and cut her clitoris with a razor blade. Often, the midwife used the same razor to cut several girls in succession.
Doctors in Iraqi Kurdistan told Human Rights Watch that the most common type of FGM believed to be practiced there is partial or total removal of the clitoris and/or prepuce, also known as clitoridectomy. Health care workers said that an even more invasive procedure was sometimes performed on adult women in hospitals. The practice serves no medical purpose and can lead to serious physical and emotional consequences.
The previous regional government took some steps to address FGM, including a 2007 Justice Ministry decree, supposedly binding on all police precincts, that perpetrators of FGM should be arrested and punished. However, the existence of the decree is not widely known, and Human Rights Watch found no evidence that it has ever been enforced.
In 2008, the majority of members of the Kurdistan National Assembly (KNA) supported the introduction of a law banning FGM, but the bill was never enacted into law and its status is unknown. In early 2009, the Health Ministry developed a comprehensive anti-FGM strategy in collaboration with a nongovernmental organization. But the ministry later withdrew its support and halted efforts to combat FGM. A public awareness campaign about FGM and its consequences has also been inexplicably delayed.
The new government, elected in July 2009, has taken no steps to eradicate the practice.
The origins of FGM in Iraqi Kurdistan are unclear. Some girls and women interviewed by Human Rights Watch said they were told that it is rooted in a belief that anything they touch is haram, or unclean, until they go through this painful procedure, while others said that FGM was a traditional custom. Most women referred to FGM as an Islamic sunnah, an action taken to strengthen one’s religion that is not obligatory.
The association of FGM with Islam has been rejected by many Muslim scholars and theologians, who say that FGM is not prescribed in the Quran and is contradictory to the teachings of Islam. Women and girls interviewed said they had received mixed messages from clerics about whether it was a religious obligation. Clerics interviewed said that when any practice interpreted as sunnah endangers people’s lives, it is the duty of the clerics to stop it.
Health care workers interviewed gave mixed responses both about their concerns about the harm FGM causes and about their obligation to raise awareness about the dangers of FGM.
Two studies have been conducted recently to try to determine the prevalence of the practice. In January 2009, the former Human Rights Ministry conducted a study in the Chamchamal district with a sample of 521 students ages 11 to 24. It found that 40.7 percent of the sample had undergone the procedure – 23 percent of girls under age13, and 45 percent of those ages 14 and older.
In 2010, the Association for Crisis Assistance and Development Co-operation (WADI), a German-Iraqi human rights nongovernmental organization, published the results of a study conducted between September 2007 and May 2008 in the provinces of Arbil and Sulaimaniya, and the Germian/Kirkuk region. Interviews with 1,408 women and girls ages 14 and over found that 72.7 percent had undergone the procedure – 77.9 percent in Sulaimaniya, 81.2 percent in Germian, and 63 percent in Arbil.
The wider age range of girls and women interviewed may account in part for the higher overall percentages. The percentage was 57 percent for those ages 14 to 18 in this study.
Human Rights Watch called on the regional authorities to develop a long-term plan that involves government, health care workers, clerics, and communities in efforts to eradicate the practice. The strategy should include a law to ban FGM for children and non-consenting adult women; awareness raising programs on the health consequences of FGM; and the mainstreaming of FGM prevention into policies and programs for reproductive health, education, and literacy development.
The government also should work closely with communities and people of influence in those communities to encourage debate about the practice among men, women, and children, including awareness and understanding of the human rights of girls and women, Human Rights Watch said.
“The government not only needs to take action to end this practice, but to work for public affirmation of a new standard – not mutilating their girls,” Khalife said.
“FGM is a complex issue, but its harm to girls and women is clear,” Khalife said. “Eradicating it in Iraqi Kurdistan will require strong and dedicated leadership on the part of the regional government, including a clear message that FGM will no longer be tolerated.”
World Parliamentarians have pledged to mobilize support for legislative actions to ensure the health, dignity and rights of women and girls through access to reproductive and sexual health in the shortest possible time.
“We are convinced that implementing the commitment made by our governments in the major United Nations conferences and summits, will end the preventable high maternal deaths and disability that constitute the greatest moral, human rights and development challenge of our time”.
This was contained in a communiqué issued at the Parliamentarians Forum during the close of a three-day world conference on “Women Deliver 2010,” which highlighted the achievements in reducing maternal mortality, breakthroughs in reproductive technology, the role of women’s health in development and the remaining obstacles to improving maternal health around the world.
The conference was attended by over 3,000 participants including national health ministers, first ladies, parliamentarians, midwives, the youth, maternal health advocates and celebrities from over 140 countries.
The parliamentarians expressed their determination by creating laws and policies with and for women and girls, giving them their fair share of funding, budget and oversight responsibilities, advocate for a women’s and girls’ agenda everywhere to advance MDG “5″, locally, nationally, regionally and globally as well as speaking out on women and girls to create awareness and knowledge building.
The MPs explained that health solutions for girls and women must be complemented by a conducive political will and legislative environment for long term results and effectiveness.
They, therefore, expressed their commitment in demanding that key issues of women and girls’ sexual and reproductive health and rights were made regular agenda items during relevant bilateral, multilateral and international meetings.
The MPs also committed themselves to generating an institutional memory by mapping legislations that governments have adhered to women and girls health and ensure their implementation, work actively towards enforcing national laws and de facto implement policies to accelerate women and girls economic, social and political rights and reduce gender inequality and gender-based violence.
They expressed concern about the funding and budget allocated to address the health needs of women and girls and called for additional 12 billion dollars a year to be invested in women and girls.
They also pledged to work in partnership with governments, civil society, the private sector and other key stakeholders to meet the 24 billion dollars needed to provide access to family planning and maternal and newborn care to all women in developing countries.
The communiqué called for active work in the establishment of a global funding mechanism for family planning, mothers saying “such a global funding mechanism would reduce maternal mortality by 70 per cent, avert 44 per cent of new born deaths, reduce unsafe abortions by over 70 per cent and further contribute to curb the AIDS and malaria pandemics, which has placed women and girls at greater risk.
“With the up-coming G-8 and G-20 parliamentarians’ conference and the summit of leaders of industrialized nations, the MPs will take the opportunity to review the MDGs.
“Now is the time to amplify our voices to broaden the dialogue on maternal and reproductive health in the global arena and to demonstrate concrete action to achieve MDG “5″, the communiqué added.
It called for parliamentarian’s participation and inclusion in political priority setting on women and girls health at local, national, regional and global levels by establishing a clear monitoring mechanism for each MDG with a clear timeline and format.
The communiqué also called on health ministers to establish realistic and verifiable annual action plans for reaching individual MDG targets with a special emphasis on MDG “5″, which will be presented during the UN High Level Meeting to be held in September 2010.
It said MPs would therefore take a leading role in communicating the societal, economic, political and cultural benefits of investing in women and girls to parliamentary colleagues, governments and other key decision-makers and private investors.
The world parliamentarians, the communiqué said, called on governments to act upon endorsed consensus on maternal, newborn and child health.
In Indonesia a woman’s lack of power over her own healthcare decisions is contributing to the high maternal mortality rate.
“Inequality in decision-making, limited access to health services in rural areas and lack of information on healthy pregnancy are among the factors that contribute to maternal deaths,” said Masruchah, secretary-general of the National Commission on Violence against Women.
“There’s a view that husbands should have final say over domestic matters, but men often don’t know what their wives feel,” said Masruchah, who like many Indonesians goes by one name.
Despite government efforts to increase the number of skilled birth attendants and promote family planning, at least 10,000 women die of childbirth related causes every year in this largely Muslim nation of more than 240 million people, according to a World Bank report published in February.
The report, ‘… And then she died,’ Indonesia Maternal Health Assessment, puts the maternal mortality rate at 228 deaths per 100,000 live births, compared with UN World Health Organization data from 2005, published in 2007, which refers to a rate of 450 in India, 62 in Malaysia and six in the Netherlands. [http://www.who.int/whosis/mme_2005.pdf]
A woman’s economic status, level of education and age of first marriage affect maternal health and the birth outcome, the report states. Three decades of increased use of midwives and almost universal access to antenatal care had not succeeded in significantly reducing the maternal mortality rate.
“Pregnant mothers are often too late in identifying danger signals during pregnancy and in making decisions, because women often have to wait for their husbands or parents to make decisions,” said Linda Gumelar, Minister for Women’s Empowerment and Child Protection.
Home deliveries and the use of traditional birth attendants have contributed to maternal deaths, with the study showing only 10 percent of poor women in two districts of the country’s populous West Java Province being attended by a health professional at the birth.
According to the World Bank report, a survey of three districts showed 63 out of 76 deaths occurred in home births assisted by traditional birth attendants.
“Interventions by the skilled birth attendants in many cases are not in line with existing standards and prove to be ineffective in trying to address the emergence of complications,” it said.
Traditional practices and myths associated with pregnancy often obstruct prompt medical intervention, said Sutan Finardhy, an obstetrician-gynaecologist who has worked in rural areas for more than 20 years.
Family members and even neighbours often advise against medical treatment for pregnant mothers.
“In some cases, husbands agreed to a doctor’s advice, but parents insisted on taking the mothers home or resorting to traditional means,” Finardhy said. “By the time the mothers had access to medical intervention, it was already too late.”
Indonesia’s 2007 Demographic and Health Survey [http://www.measuredhs.com/pubs/pdf/FR218/FR218%5BApril-09-2009%5D.pdf] indicates inequity between provinces – with 97 percent of births attended by skilled providers in Jakarta, against only 33 percent in the Maluku Islands.
The World Bank said only 40 percent of the country’s 68,816 villages had a midwife in 2005.
The report urged the government to improve the training institutions, increase the number of obstetricians, gynaecologists and anesthesiologists, and increase overall funding for maternal health across the country.
There has been some increase in the number of women accessing antenatal healthcare services in Yemen over the past four years, but most mothers still deliver at home and their health situation remains rather bleak, according to new reports from the Ministry of Health and the World Health Organization (WHO).
The proportion of women benefiting from antenatal healthcare services has increased from 40 to 55 percent over the past four years, according to an 18 May Health Ministry report covering 2006-2010.
At a conference in Sanaa on 18 May sponsored by the National Women’s Committee and the Health Ministry, some women’s rights activists criticized slow progress in antenatal healthcare coverage.
UN Population Fund (UNFPA) deputy representative Zeljka Mudrovcic said 22 women die in Yemen every day due to pregnancy and birth-related complications.
“As 80 percent of women deliver at home, much more needs to be done to improve antenatal health care for women and reduce high mother and infant mortality rates,” she said.
The Ministry of Social Affairs and Labour, supported by UNFPA, launched on 17 May the distribution of 30,000 clean and safe home delivery kits for the year 2010 in an effort to improve this situation.
According to WHO’s 10 May World Health Statistics 2010 report, [http://www.who.int/whosis/whostat/2010/en/index.html] Yemen’s maternal mortality rate was 430 cases per 100,000 live births, the highest in the Middle East.
Antenatal care coverage (“the percentage of women who used antenatal care provided by skilled health personnel for reasons related to pregnancy at least once during pregnancy, as a percentage of live births in a given time period”) was 47 percent – the lowest in the Middle East, according to the report.
Repeated miscarriages and post-natal bleeding – particularly among girls in rural areas – are among the major factors behind the high maternal mortality rate in the country, according to Nema Naser al-Suraimi, a specialist doctor in obstetrics and gynaecology at al-Thawra Hospital in Sanaa. “In rural areas, miscarriage is commonplace, particularly as 52 percent of girls marry before the age of 15,” she told IRIN.
Yemen’s adolescent fertility rate (births per 1,000 girls aged 15-19 years) stands at 80, according to the WHO report.
“In many remote villages where health facilities don’t exist or are very far away, many women die inside cars on their way to [maternity] hospitals in provincial capitals,” al-Suraimi said. “Women in rural areas don’t receive basic health care from the beginning of pregnancy and therefore are prone to multiple birth-related complications.”
According to Mohamed Ghurab, another obstetrics and gynaecology specialist at the Sanaa-based Republican Hospital, 70-80 percent of maternal deaths can be avoided by raising public awareness of the risks of home delivery.