New blog for Bererblog readers

Bererblog readers might be interested in the new RHM BLOG which includes comment and analysis from Reproductive Health Matters staff and guest bloggers on topical SRHR issues. Since launching we have added these posts:

Caesarean: who defines acceptable risk – the woman, the doctor or the courts?

Reproductive coercion: one step forward, two steps back?

Unnecessary hysterectomy in India; the deeper scandal – a guest blog by Sapna Desai

Rape the stereotyping of Indian culture and moving from ‘protection’ to ‘freedom‘ - a guest blog by Pooja Badarinath

It’s also a place where you can find Reproductive Health Matters’ responses to current consultations:

Comments on the Report of the Global Thematic Consultation on Health submitted by Reproductive Health Matters

RHM’s submission to ‘The World we Want 2015′

Marge is going to continue blogging here so watch this space…

Depo Provera and the news that broke earlier this year from Israel

Marge Berer, Editor, Reproductive Health Matters

The news that broke earlier this year from Israel, that Ethiopian Jewish women had been given the injectable contraceptive Depo Provera without their knowledge or consent, awakened a strong feeling of déjà vu for me. This is where I came into this field, 35 years ago. Depo Provera had recently come onto the market for the first time. There were far fewer contraceptive methods available at the time and therefore far less choice. A method that a woman need only renew once every three months was a gift, from one perspective. One injection four times a year and no fear of unwanted pregnancy, no need to insert anything, wear condoms, remember to take a pill every day, get your partner’s agreement if he was opposed to using something. It was heralded as the solution to high levels of unwanted pregnancy.

At the same time, the potential for abuse of this method was obvious from the beginning, and abuse there was from paternalistic family planning providers. The “irresponsible woman”, who kept coming back for abortions, women who were poor, uneducated or with learning difficulties, who didn’t understand contraception or the importance of limiting births, were seen as the ideal candidates for Depo Provera. Middle class, more educated women stayed with the pill or got a copper IUD. HIV hadn’t appeared yet and condoms had become a thing of the past with the advent of the pill in the 60s. Diaphragms were what our mothers had had to use, with or without condoms, when there was nothing else. You had to be over 30 to be sterilised. Modern contraception was barely 20 years old and it was truly liberation for my generation, as it still is.

At the same time, however, the Dalkon Shield IUD, an IUD which was thought to increase the risk of upper reproductive tract infection because of the nature of its string (extending into the vagina for removal purposes), believed to facilitate the conduction of infection upwards, caused a hue and cry. Due to action by US feminist women’s health activists at the time, the method was withdrawn from the market and the reputation of all IUDs suffered for many years. Young women, who with hindsight and greater knowledge we can guess were getting sexually transmitted infections in large numbers as they experimented with sex, were not allowed to have IUDs because of this risk, when in fact, it was probably the sexual networking that was unsafe, as we learned when HIV hit the globe.

Even so, as part of a small but very vocal international feminist women’s health movement who supported women’s reproductive rights and opposed “population control”, I wrote a pamphlet called “Who needs Depo Provera?” in 1983, which was distributed pre-computer very widely both in the UK and other countries. Reading it again now, I am embarrassed to find how completely negative it was. It not only expressed fears of the potential for abuse of informed consent with the method, which remains justified. It was also so negative about the known side effects that anyone reading it would be completely put off, even if the method might have suited them. And it expressed exaggerated fears about the long-term safety of the method, which at the time was unknown because studies of long-term safety had not been conducted. We conflated the existence of negative side effects (to do with effects on menstrual bleeding, weight gain and mood changes) which do exist and may affect women, with an assumption that long-term safety was a problem. There was just enough evidence of possible issues to create this concern, but instead of expressing it with caution and uncertainty, in a scientifically justified manner, we used it to condemn the method.

Our action against Depo Provera, which included a protest outside the Committee on Safety of Medicines (because we were not allowed to give evidence or raise questions in their hearings on approval of the method) had many consequences. A good consequence was that long-term safety studies were initiated and became a standard part of contraceptive research and development. Another was that we contributed to the recognition of the importance of the concept of informed choice as regards using contraception, in place of “doctor knows best”. Informed choice, which the movement was demanding all over the world, became accepted in mainstream family planning and something that women expected. (I’m simplifying a very complex set of events over many years here, in order to be brief.)

On the negative side, however, there have been two lasting ill-effects. The first was exemplified in Zimbabwe at the time, where Depo Provera was pretty much the only available contraceptive. The government took the decision to focus its family planning programme around this method, whether due to the cost implications of a choice of methods, or because primary level family planning providers could most easily deliver it, or out of awareness that men did not understand the value of contraception and were widely opposed to it, and this method could not be removed by them, or because women were having more children than they wanted and the method is highly effective – most probably for all these reasons. Women in Zimbabwe accepted Depo Provera for its benefits and had begun to use it widely. That programme was very negatively affected by our actions in the UK and elsewhere. This was not a victory, as we believed at the time. On the contrary, it was a costly and terrible mistake.

Secondly, to this day, some feminist women’s health activists remain negative about Depo Provera and other longer-acting hormonal contraceptive methods, even though their benefits are clear, their side effects are no longer a secret and are explained to women more often, and their long-term safety has been studied and confirmed. Their opposition has been carried over to implants, IUDs, and medical abortion pills, in effect splitting the feminist women’s health movement into conflicting camps, and continues to have the very negative effect of limiting the still limited choices women have for preventing and terminating pregnancy.

On the other hand, the potential for abuse of injectables – because they are easy to administer in the context of other services without necessarily explaining what it is, and of implants because they require surgical removal, and of sterilisation because it is permanent and difficult or impossible to reverse – remains. Such abuses are not a thing of the past. They emerge regularly, as Lisa Hallgarten has shown in a recent blog, citing a number of RHM articles, whether due to pressure to meet targets, racist efforts to reduce births among ethnic minority populations, or discriminatory efforts such as to stop women with HIV from having children.

But there are some big differences between what was happening in the 20th century and what is happening now. The most important is that there is widespread recognition that these are abuses so that, when they emerge into the light of day, something is more often done (and sometimes done quickly) to stop them, including through public investigation, the courts and the UN human rights system – as has happened in Israel with Depo Provera and with sterilisation of HIV-positive women in southern Africa. (Though not quickly enough in Eastern Europe for Romany women, who got little support for a long time.) Mass abuse such as the sterilisation camps in India under Indira Gandhi in the 1970s, is hopefully far less likely. Still, the need for vigilance remains.

Secondly, the new “family planning initiative” in seeking to greatly increase access to contraceptives, which is a very good thing, knows it cannot afford to be tarred with the brush of failing to deliver informed choice. It is being very cautious about targets, even though it is calling for them. It says it supports informed choice and a rights-based approach, even though these are inconsistent with targets in the hands of a system that punishes health workers for failure to reach targets. This is an ongoing discussion; it may not be unalloyed progress, but it is definitely progress of a kind.

Headlines! The Pope is the first to step down in 600 years

Marge Berer, Editor, Reproductive Health Matters

We all have to decide when it’s time to step down as we age, and now we can say “even the Pope”. I’m a few decades younger than him but I can already see that decision waiting in my future too. Maybe he is too frail in mind and body. At his age, he has a right to be. Maybe he’s had one too many scandals related to sexual abuse to deal with, and he doesn’t want to cope with any more, or know what to do about them, or how to prevent more of them taking place without compromising what he stands for. I’m sorry he is unwell, but I’m glad to see the back of his policies.

My hope is that his virulent misogyny, dressed in sheep’s clothing, his support for women’s deaths through unsafe abortion, his unswerving opposition to condoms and contraception, his condemnation of so many aspects of sexuality, are all stepping down with him, never to return.

Termination of pregnancy as emergency obstetric care: the interpretation of Catholic health policy and the consequences for pregnant women. An analysis of the death of Savita Halappanavar in Ireland and similar cases

Marge Berer, Editor, Reproductive Health Matters

Below is a summary of the article in full  Termination of pregnancy as emergency obstetric care

On 28 October 2012, Savita Halappanavar miscarried at 17 weeks of pregnancy and died in the maternity ward of a hospital in Ireland. Twelve weeks later, articles and blogs about her death continue to be published in many countries. What was iconic about Savita’s death was the fact that it raises questions about whether to terminate a pregnancy as emergency obstetric care, e.g. for inevitable miscarriage, where there are severe fetal anomalies and other non-viable pregnancies, or to save a woman’s life or health. As a committee of the Irish Parliament considers proposals to offer limited legal abortion in Ireland, this paper explores how these questions arose in relation to Savita’s death, how they relate to the interpretation of Catholic health policy and the consequences for pregnant women’s lives.

Part of the treatment required to save Savita’s life, carried out without delay, was to terminate the pregnancy because her cervix was fully dilated, the pregnancy was no longer viable and she was at high risk of infection. This was not, apparently, how Savita’s doctors saw the situation, or at least not what determined the action they took. Based on what was reported in the media, termination of the pregnancy appears to have been delayed because there was still a fetal heartbeat. But why?? What appears to be the answer arises from a statement by the doctors involved in Savita’s case that “this is a Catholic country” and, in the cases of other women reported in the media afterwards, with direct reference to personal or hospital-wide interpretation of Roman Catholic health policy.

A 2009 judgement by the now Chief Justice of the Irish Supreme Court has been interpreted to mean that if a fetus cannot survive beyond pregnancy it does not enjoy the protection granted in the Irish Constitution to the “life of the unborn”. In November 2012 the Standing Committee of the Irish Catholic Bishops’ Conference said: “· The Catholic Church has never taught that the life of a child in the womb should be preferred to that of a mother. By virtue of their common humanity a mother and her unborn baby are both sacred with an equal right to life… Whereas abortion is the direct and intentional destruction of an unborn baby and is gravely immoral in all circumstances, this is different from medical treatments which do not directly and intentionally seek to end the life of the unborn baby. Current law and medical guidelines in Ireland allow nurses and doctors in Irish hospitals to apply this vital distinction in practice while upholding the equal right to life of both a mother and her unborn baby.”

The requirement “to uphold the equal right to life of both a mother and her unborn baby” is the crux of the problem, however, because in a case like Savita’s and many others, the mother and fetus do not have an equal chance of survival. Catholic policy signally fails to acknowledge this, to women’s great detriment. The fact that the fetus is still alive is what appears to make all the difference ̶ because it forces medical professionals to decide whether the death of the fetus would be “directly intended” or not. This was fatal for Savita and is potentially fatal for other women.

The paper goes on to describe a number of other such cases, including those described by obstetrician-gynaecologists in six Catholic-run hospitals in the USA, individual cases in the Dominican Republic and Costa Rica, and those of other women in Ireland from the past which have emerged. Finally, it describes a US case where a Catholic-run hospital decided to terminate a pregnancy to save a woman’s life and was officially stripped by the Bishop of its Catholic affiliation.

This paper asks: is refusal to terminate pregnancies because the fetus is still alive, no matter what risk they pose to women, the norm in Catholic maternity services? If so, in which countries? Or are these cases exceptions?? It argues that the governments of Ireland and of every other country with Catholic-run maternity services need to answer these questions urgently.

Many of the events presented in this paper are recent or have only just taken place, and most of the sources are media and individual reports. However, there is a very worrying common thread running across countries and continents. These reports invite rigorous investigation of emergency obstetric care provided by Catholic maternity services and Catholic health professionals.

If such research unearths more histories of failure to treat and save women’s lives, as in the cases reported in this paper, urgent action is called for, including stripping any such health professionals and/or hospitals of their right to provide maternity services and emergency obstetric care. At issue is whether the woman’s life comes first or not. This is the crux of what abortion as well as emergency obstetric care is all about.

Full article available here

FGM: condemn globally, act locally

Lisa Hallgarten, Reproductive Health Matters

We should all celebrate the news that on Thursday 20th December 2012, the United Nation’s General Assembly unanimously passed a resolution banning the practice of Female Genital Mutilation (FGM). Resolutions to eliminate FGM are important. When they are passed in a global forum, they may pre-empt the claims of cultural relativism which try to prevent us talking critically across nations and cultures about FGM and other dangerous or unethical practices.

However, the process of eliminating FGM can only happen when initiatives are developed at local level and informed by the specific beliefs, practices, unmet needs and politics of the areas where it is prevalent. This is perfectly illustrated by an article in the new Reproductive Health Matters (1)  which reports on beliefs in some ethnic groups in Tanzania in which FGM is still practised, over 40 years after it was made illegal.

The article reports on findings from nine years of work combatting FGM in 45 villages  in Tanzania. FGM has, historically, been widely practiced in 12 ethnic groups living in seven of Tanzania’s 24 regions: the Gogo, the Rangi and the Sandawi of Dodoma, the Nyaturu of Singida, the Chagga of Kilimanjaro, the Waarusha of Arusha, the Luguru of Morogoro, the Maasai, the Iraqw, the Barbaig and the Hazabe of Manyara, and the Kurya of Mara region.

Until the late 1960s FGM was carried out on girls between eight and twelve years old. It was an essential part of community rituals and celebrated openly. In 1968 FGM was criminalised, but far from ending the practice, criminalisation led to FGM going underground. Most significantly it led to the development of a narrative that explains and promotes the practice and gives it a new legitimacy. The new narrative identifies FGM as both a preventive against, and cure for urinary tract and genital infections known locally as lawalawa.

Lawalawa affects young infants and children – resulting mainly from lack of clean water and poor hygiene practices – so by the 1970s it was being said that ‘circumcising babies was necessary in order to cure a mystic spell (lawalawa) placed on them by the ancestors.’  In this way FGM became increasingly removed from the public space and detached from the original ritual purpose and meaning of the practice. “It seems that (they) invented lawalawa to legitimate FGM, even though the performance had to lose some of its meaning.” The authors conclude that steps must be taken to educate people about and address the real causes of lawalawa, and also effectively to disseminate information about medical care that is available to treat infections.

This may be a very particular cultural context, but the paper has a universal message. All ritual and cultural practices are perceived by the community in which they take place as serving a purpose. Wherever it happens in the world FGM is justified in different and specific terms. This paper illustrates that fundamentally changing attitudes across the community and from within the community is the only way to move towards the elimination of FGM.

I’m all for global condemnation and local engagement.

(1) Ali C, Strømb A. ‘It is important to know that before, there was  no lawalawa.’ Working to stop female genital mutilation in Tanzania. Reproductive Health Matters 2012; 20 (40):69-75

Contribution of research in RHM Journal to dramatic improvements in post-abortion care, Gabon

Lisa Hallgarten, Reproductive Health Matters

We know that RHM is read in the highest offices and the humblest clinics. Papers we publish provide the evidence to change government policies and support change at the level of clinical practice…and this happens. In our most recent issue of Reproductive Health Matters one paper reports on the impact of changes made as a result of research published in an earlier journal issue.

In 2009 RHM published a paper (1) on the delays in care experienced by women who died from complications of unsafe abortion and other maternal complications in Centre Hospitalier de Libreville, Gabon. The results showed an ‘abysmal difference in delay providing care, from just over one hour for women who had died of eclampsia or postpartum haemorrhage, to 23.7 hours for women who had died from unsafe abortion complications’. The authors measured the time between identification of the problem and initiation of care and concluded that discriminatory treatment, in the context of a culture of abortion stigma, was a factor in the delays. The delays were ‘not due to any lack of life-saving equipment or supplies, or of properly trained personnel, because no such delays were observed in the treatment of the women who died from other causes in the hospital in the same time period.’ The authors suggested this might be the first study to directly link such discrimination with an increased risk of death and called for the hospital to address discriminatory practice in the hope that this might lead to a decrease in abortion-related mortality.

An article in the current issue of RHM provides evidence of ‘dramatic improvements in post-abortion care in the same hospital in Gabon’. The authors of the study (2) report that the original findings were presented to the government and to the hospital authorities. Following this, women with complications of abortion were given a higher priority, and there was a change in the kind of care provided. Changes in care included a shift to manual vacuum aspiration (MVA) under local anaesthesia for two thirds of women, with care provided by midwives in half of those: by contrast in 2008 all cases were treated with surgical methods that required general anaesthetic and care from a doctor. The authors suggest that it was these changes that led to a ‘ten-fold reduction in the average time from admission to treatment for abortion complications in only a few years’. Though they cannot demonstrate a cause and effect, the study finds that awareness raised by the original report ‘was the main determining factor in the observed change.

Authors found a  low rate of complications following MVA, which they say confirms ‘the capacity of properly trained mid-level providers to master this technique.’ Hopefully this finding will be presented to hospital authorities and governments elsewhere and help inform the provision of services for women presenting with complications of unsafe abortion wherever they are.

(1) Mayi-Tsonga S, Oksana L, et al. Delay in the provision of adequate care to women who died from abortion-related complications in the principal maternity hospital of Gabon. Reproductive Health Matters 2009;17(34):65-70.

(2) Mayi-Tsonga S, Assoumou P, et al. The Contribution of research results to dramatic improvements in post-abortion care: Centre Hospitalier de Libreville, Gabon. Reproductive Health Matters 2012; 20(40): 16-21.

Pregnancy decisions of women living with HIV – and a happy World Aids Day

A new RHM supplement explores pregnancy decisions of women living with HIV. It’s free to download here.

In 2007 we published this supplement on Ensuring Sexual and Reproductive Health for People Living with HIV. It will be interesting to ring the changes. With the advent of antiretroviral therapy and with continued channelling of resources into HIV services, greater numbers of HIV-positive women are living longer, healthier lives. As a result, they are contending with a range of issues affecting their sexual and reproductive health and rights. The new supplement aims to determine ways to work across disciplines and life experiences with the ultimate goal of ensuring that women living with HIV are at the centre of decision-making about their sexual and reproductive health and rights.

The supplement responds to an identified need for a stronger evidence base; drawing from biomedical, economic, political, legal and social science perspectives alike. It also recognises the importance of moving beyond disciplinary silos to bring these perspectives together in order to provide more comprehensive information relevant to the lives of women and men living with HIV, as well as to create demand for appropriate services and policies.

The supplement grew out of a conference on HIV and pregnancy at the Harvard School of Public Health in March 2010, where it was noted that despite recent attention to the sexual and reproductive health concerns of HIV-positive women in some specific areas, the challenge remains to ensure the voices of HIV-positive women are heard and to address relevant issues from multidisciplinary perspectives.

We have included papers here that represent a diversity of topics, experiences, geographical areas and disciplines. Taken together these papers are intended to help drive policy, programmatic, research and advocacy efforts to promote and protect the sexual and reproductive health and rights of women living with HIV.

Titles include:

• The pregnancy decisions of HIV-positive women: the state of knowledge and way forward

• Exploring the relationship between induced abortion and HIV infection in Brazil

• The impact of antenatal HIV diagnosis on postpartum childbearing desires in northern Tanzania: a mixed methods study

• HIV, unwanted pregnancy and abortion – where is the human rights approach?

• How the global call for elimination of paediatric HIV can support HIV-positive women to achieve their pregnancy intentions

• If, when and how to tell: a qualitative study of HIV disclosure among young women in Zimbabwe

• Towards an HIV-free generation: getting to zero or getting to rights?

• A conceptual framework for understanding HIV risk behaviour in the context of supporting fertility goals among HIV-serodiscordant couples

• The pregnancy decisions of HIV-positive women: the state of knowledge and way forward

• The role of men as partners and fathers in the prevention of mother-to-child transmission of HIV and in the promotion of sexual and reproductive health

• “Shemade up a choice for me”: 22 HIV-positive women’s experiences of involuntary sterilization in two South African provinces

• Hormonal contraception and risk of HIV acquisition: a difficult policy position in spite of incomplete evidence

• Positive and pregnant – how dare you: a study on access to reproductive and maternal health care for women living with HIV in Asia

The supplement editor is Sofia Gruskin, Program on Global Health and Human Rights, USC Institute for Global Health.

Download the new supplement here