The announcement regarding the decision to allow Beatriz in El Salvador to have a “premature delivery” requires a continuing response from the abortion rights community.

The article states: “The medical team at the Maternity Hospital is ready to act immediately at the slightest sign of danger.” In fact, the opposite is true. Danger signs have existed in Beatriz’s pregnancy from the beginning. Instead of acting on them and terminating the pregnancy as soon as it was known that the embryo had no chance of survival, if not sooner, the medical team of the hospital has put her life at constant risk. Like Savita Halappanavar in Ireland, Beatriz’s condition could  suddenly worsen, e.g. her blood pressure could go out of control, her kidneys could fail, and she could die in a short space of time.

No one in the hospital or the Ministry of Health of El Salvador should be allowed to get away with the falsehood that her care is in good hands. Her care is in the hands of people who have been prepared to let her die for the sake of a fetus with no brain, but with only a heartbeat and without the chance of a life.

She will be “allowed” to have a caesarean section, described as a “premature delivery”. Why a c-section, why surgery? Is this justified because it is the safest possible form of delivery for her? Can someone explain this please? What is wrong with either a dilatation & evacuation, or induction with mifepristone and misoprostol? Both surely carry fewer risks?

Please recall the case of “Aurora” in Costa Rica, at the end of 2012, who was also carrying a fetus with no chance of life, a fetus whose heartbeat stopped only at 29 weeks of pregnancy. She also was then given a c-section. Some of us asked why that was necessary at the time, but no one raised the question or challenged it publicly. It is time to ask publicly: why is a c-section the delivery method of choice? Is it only because it is the only form of termination of the pregnancy that they think cannot be labelled abortion?

Are these two cases representative of a new “Catholic health policy” for pregnant women with an emergency obstetric situation involving a non-viable embryo/fetus – that they are imprisoned in a hospital, in some cases  for months,  denied a life-preserving abortion until the fetal heartbeat stops, and then delivered of the dead baby by the highest risk procedure possible for the woman, a caesarean section?

Beatriz’s treatment should be considered cruel and degrading treatment and a violation of the Hippocratic oath to do no harm. The protest here is not finished; it is only beginning because cases like Beatriz’s and Aurora’s are only just coming to light through the vigilance and action of human rights and women’s abortion rights groups. What we need to challenge is not just the abortion laws of El Salvador, Costa Rica, Ireland and other countries where even abortion to save the life of the woman is not permitted. We need to challenge the Ministers of Health, parliaments, Supreme Courts, hospitals and clinicians in every country whose clinical decisions and actions are subservient to the dictates of the Roman Catholic Church’s “health policy” on abortion, which blatantly and cruelly disregards the right to life and health of pregnant women. Whose bottom line is that even with a non-viable embryo/fetus with a heartbeat but no chance of survival a termination is never permissible.

RHM has just published my paper analysing Catholic health policy on emergency obstetric care involving termination of pregnancy which discusses all the cases I could find that have come to light up to several months ago:

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

It seems this is not an uncommon problem. If health professionals systematically put the lives of their patients at risk for any other ideological non-clinically justifiable reason, it would not be tolerated. I believe any Catholic health professionals and/or hospitals refusing to terminate a pregnancy as emergency obstetric care should be stripped of their right to provide maternity services. In some countries these are the main or only existing maternity services. Even so, governments should refuse to fund these services, and either replace them with non-religious services or require that non-religious staff are available at all times specifically to take charge of such cases to prevent unnecessary deaths. At issue is whether a woman’s life comes first or not at all.

Previously posted in RH Reality Check – June 1st 2013

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…

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.

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.

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

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

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.

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

Blog one – What is Open Access and how far has it spread?

Since the launch of the Open Access Initiative in Budapest in 2002, sponsored by the Open Society Institute, its proponents have sought to keep momentum in the academic, publishing and political spheres towards the fulfilment of a declaration of principles, and celebrated the 6th “Open Access week” on 22-28 October 2012. Reflecting on some of the discussions held during Open Access week, this blog series looks at how Open Access has evolved, its implications for publishing in general and, in particular, for Reproductive Health Matters.

The idea behind Open Access is that in the age of the internet, peer-reviewed journal papers should become a public good, with free and unrestricted access to them for all. The Open Access “movement” was consolidated in response to the rapid development of internet and digital technology, as well as growing concerns about the inaccessibility of printed scholarly literature. According to its proponents, the removal of “access barriers” will “accelerate research, enrich education, share the learning of the rich with the poor and the poor with the rich, make this literature as useful as it can be, and lay the foundation for uniting humanity in a common intellectual conversation and quest for knowledge”. Open Access means “free availability on the public internet, permitting any users to read, download, copy, distribute, print, search, or link to the full texts of these articles, crawl them for indexing, pass them as data to software, or use them for any other lawful purpose, without financial, legal, or technical barriers other than those inseparable from gaining access to the internet itself”. Authors should be given control over the integrity of their work and be properly acknowledged and cited, but any other constraints on reproduction and distribution would no longer be acceptable.

There are two approaches to Open Access online publishing:

“Gold” Open Access is when papers are published by journals which do not charge a subscription fee but do charge authors or their institutions a fee to publish their papers. See for example, PLOS.

“Green” Open Access is when papers published in journals that do charge a subscription are subsequently self-archived by authors in an online repository (complying with any conditions set by the journal that originally published the paper). See, for example, UCL Discovery. A directory of Open Access repositories can be found here.

According to the initial statement of principles, these two Open Access strategies should be complementary.

How far has Open Access spread?

According to the Open Society Foundations, Open Access is now mandated by over 300 research funders and institutions worldwide. Information published by the ROARMAP  registry of Open Access repositories shows these are primarily – though not exclusively – situated in Europe, followed by North America. The US National Institutes for Health (NIH) set new ground in 2008 by adopting a Public Access Policy  requiring that all papers based on NIH-funded research be made publicly accessible through the digital archive PubMed Central no later than 12 months after official publication. Similarly, the UK-based Wellcome Trust requires papers based on any research they fund in whole or in part to be available through a PubMed Central repository.

As of 2011 approximately 17% of scholarly journal articles are now made openly available on the internet through Gold Open Access journals. While initially Open Access publishing was driven largely by scientific and professional associations, universities and individual researchers, nowadays commercial and new so-called “professional non-commercial” publishers have overshadowed these. Online-only journals have sustained stronger growth in providing Open Access content, while print journals that provide Open Access output have plateaued.

Regarding “green” Open Access repositories, institutions and funders at a recent discussion at Birkbeck College, University of London said that researchers’ compliance with self-archiving rules was far from complete. The Wellcome Trust, for example, recently acknowledged  that only 55% of research papers acknowledging its funding comply with their Open Access policy. It has announced efforts to strengthen enforcement (including withholding final grant payments and discounting non-compliant publications in future funding applications).

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Blog two – Open Access: the flip side

Proponents of Open Access claim it is an “inevitable consequence” of the internet, yet it would be foolish to underestimate the implications for research, publishing and dissemination across the world.

The implications of Open Access fall into three main categories:
1. Costs and funding
Open Access is leading to a dramatic change in the economics of research publication and dissemination. Not being able to generate income from subscription fees, Open Access journals are increasingly charging authors “article processing” fees, to be paid either on submission or on acceptance of an article for publication. Research shows that article processing fees range from USD 20 to USD 3,800, with an average of approximately USD 900. Because of the number of different publication models it is difficult to determine exactly what proportion of journals currently charge article processing fees, but research does show that of 4,319 online-only Open Access journals published in 2011, 42% levied fees. It is easily conceivable that with the growth in online Open Access publishing, the practice of charging author fees may spread further. Among those that already charge are some major players in scholarly publication, and research shows the link between high impact factors and high article processing charges. In this way, it appears that Open Access is merely shifting the costs of publishing from subscribers to authors.
To make things more complicated, a “hybrid Open Access” model has also emerged, whereby subscription journals publish articles according to their normal terms and conditions, but allow authors to make their work “Open Access” on payment of a fee. The American Journal of Public Health is one such example. One study reports uptake of this model at 2%.

Some research funders, such as Wellcome in the UK, have stated their commitment to including additional funding to cover article processing fees in their grants, but anyone without such funding would have to pay out of pocket to get their work into the public domain. This is highly likely to discriminate against authors from the global South, whose institutions are less likely to be able to cover such fees, as well as anyone conducting independent research, or working in poorly funded fields. Furthermore, money available for research itself may be reduced by the need to pay article processing fees – either because the research funder chooses to allocate money from its overall budget to this purpose, or because the institution receiving the money decides to spend funding from research grants on these fees.

Some journals are attempting to mitigate these problems for researchers from the global South. The International Journal for Equity in Health, for example, states that it “routinely” waives charges for authors from low-income countries, and allows a limited number of waivers at editors’ discretion. Good intentions notwithstanding, such policies place the onus on the author from a low-income country to ask to be treated as an exception. Furthermore, the criteria for this exception could easily miss out other needy researchers, such as those in the rest of the world working in poorly funded NGOs and institutions. Finally, the very fact of having to ask to be considered for a ‘waiver’ is demeaning and likely to discourage authors.

Regarding the Green Open Access model, the costs and technological requirements of setting up a repository should also not be overlooked.

2. Standards
Some argue that generating income through authors paying Open Access fees rather than subscription costs inevitably provides a greater incentive for publishers to accept work that may not meet rigorous quality standards. Perceptions that Open Access content is inferior to content behind paywalls or in print journals are certainly widespread.

Furthermore, if setting up or running a journal becomes an attractive profit-making enterprise rather than a means to advance scholarship, it is quite conceivable that private actors with specific agendas (such as pharmaceutical companies) will seek to do so, as a way to wield greater influence. Some traditional scholarly publishers have expressed concern that Open Access undermines their ability to generate income through subscription costs, which they see as crucial to the wider scholarly activities and publishing processes (including peer-reviewing processes) that maintain high academic standards.

3. Distribution and access
Open Access is predicated on access to the internet, and undoubtedly makes promotion of published research via social media much easier. Although making far greater amounts of information available to those with internet access, including those without institutional affiliations, the prioritisation of virtual over print publication inevitably restricts availability to those without access to the internet. Influenced by the advent of Open Access, funding priorities are shifting away from supporting printing costs, making it increasingly hard to find resources for printing, even if this is in many areas the only or the best way of disseminating research again particularly in the global South.

Thus, there is a big gulf between the potential and the actual possibility of achieving fully free access to journals and articles for authors and readers via Open Access.

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Blog three: the meaning of Open Access for RHM

The third in our blog series on Open Access publishing see first and second blogs.

Open Access has undoubtedly been a game-changer for traditional publishing. Questions are being widely asked about the role and responsibilities of publishers and journals in this new scenario, and politically, the commercial interests of publishers have proved sensitive[1].

Like many journals, RHM is reflecting on its own place within this rapidly changing panorama, but for us, the discussion is quite different to most journals.

How RHM is currently published

Print version

-          In English: tiered subscription rates for institutions and individuals; free for developing country groups (86% of current readers).

-          In Arabic, Chinese, French, Hindi, Russian, Portuguese, Spanish: free for all readers.

 Online version

-          In English: free to print subscribers and to those with free subscriptions. Editorials and “article of the month” available free of charge. All     content available free after 3-year embargo period. Single articles available for purchase from Elsevier ($12 per article) or Science Direct ($31.50 per article). All content available from Science Direct as part of (paid-for) bundles of journals.

-          Post-embargo all content available through HINARI (WHO’s Health InterNetwork Access to Research Initiative database, for institutions in low income countries) and Jstor (tiered subscription for libraries and others).

-          In other languages: all content available free.

 Other

-          Elsevier distributes but does not own RHM and publishes RHM online. It gains income from subscriptions and downloads, and from a fee charged to RHM.

-          RHM accepts no payments for publication, actively seeks contributors from the developing world, and secures peer reviews free of charge.

-          Authors and peer reviewers receive free copies of the issue they contributed to. 

-          Bulk subscriptions are discounted.

RHM’s unique publishing model brings it in some ways very close to what is known as Open Access. Unlike most academic journals, RHM relies on external funding to support production, publication and dissemination. In addition to openly accessible online content, distributing free printed copies in the developing world ensures that RHM is widely read in places where traditional scholarly publishing is largely unavailable. Working closely with new authors and researchers to support them to be able to publish important research and analysis is at the core of RHM’s mission: the idea of charging “article processing fees” is inconceivable.

While at face value the principles of the Open Access movement appear to be in line with RHM’s outlook and current modus operandi, the practices of many journals implementing Open Access policies – charging authors to publish and lowering standards in particular – are at odds with RHM’s principles. The concern that the developments in Open Access will lead to new inequities among authors and researchers, lower standards, and greater influence from profit-making motives, is very real. Rather than getting swept up in a movement which in practice does not always live up to its aspirations, we believe RHM should defend its sui generis publishing model. In a context where donors are increasingly reluctant to fund free subscriptions of a journal to developing countries, RHM is committed to considering how its existing form of open access could become even more open and accessible than at present, but any changes must be aimed at further strengthening its reach rather than undermining its founding vision.

[1] A draft Act that would have required express consent from publishers for the dissemination of private sector research was presented to the US Congress in December 2011. This Act has been widely criticised as protecting publishers’ interests at the expense of democratising access to research findings. In response to the initial support of the publisher Elsevier to this Act, a petition to boycott them gathered nearly 13,000 signatures. Elsevier subsequently withdrew its support, and the Act has stalled.

Exploring Open Access: more places to look

Directories:
ROARMAP provides a list of all the institutions worldwide that have registered “Open Access Repositories Mandatory Archiving Policies”.
DOAJ is a directory of Open Access journals.
OpenDOAR is a directory of Open Access repositories.
SHERPA/RoMEO is a directory of “hybrid Open Access” journals, i.e. those who do not charge for publishing an article according to normal terms, but allow authors to make published articles Open Access on the payment of a fee.
HINARI Access to Research in Health Programme database.

Other information and examples:
Wikipedia charts the history of the Open Access movement and has a useful analysis of related processes and evidence.
OpenAIRE, the European Commission’s Open Access portal gathers information on Open Access policies across the European Union.
PeerJ is a new Open Access journal for biological and medical sciences, which charges a lifetime membership fee rather than charging pay-per-publish fees. PeerJ secured $950,000 in start-up funding, and will support itself subsequently through membership fees.
eLife is a researcher-led digital journal, set up in collaboration between funders and researchers with the aim of “accelerat[ing] scientific advancement by promoting modes of communication whereby new results are made available quickly, openly, and in a way that helps others to build upon them”. All work is published under a Creative Commons Attribution Licence which allows use and re-use of all content providing the original source and authors are credited.
Feminists@law open access journal of legal scholarship editorial, “Why We Oppose Gold Open Access”
Free Journals Act, the campaign for freely accessible scientific journals, supported by 154 journals worldwide.

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Blog four: a view on Open Access publishing from Lebanon

By Jocelyn DeJong. Professor, Faculty of Health Sciences, American University of Beirut and Coordinator, Reproductive Health Working Group (Arab countries and Turkey); and Trustee of Reproductive Health Matters

As a researcher based in a middle income country, I would like to support the concerns raised by Louise Finer in blog two of this series.

While many of us welcome the advent of open-access publication and the principles it represents, there are problems in the implementation of open-access publishing as it is currently evolving. Before turning to some of these problems, however, it should be said that the status quo before the advent of open-access publications also had many deficiencies and was inequitable both in access to and production of knowledge. This status quo has meant that, although most international, peer-reviewed journals published by commercial publishers had become available electronically, there is strict legal regulation (due to international intellectual property protection) over their availability and circulation. We have also become accustomed to a publishing model where, typically, researchers and reviewers who do the bulk of work for such journals are unpaid, yet subscription prices are high and rising often making them inaccessible. In the region where I work, and indeed in most low and middle-income countries, only the more well-endowed universities are able to afford journal subscriptions. This has led to a situation where only individuals working in institutions which can afford the high cost of international peer-reviewed journals (such as my own) have access to new research findings. And even for students in universities that do have journal subscriptions, they lose the privilege of access to such journals upon graduation. They therefore start their professional lives – whether in Lebanon or in other countries – having been exposed to the value of research and having become eager to do research themselves but restricted in their access to new research. Individuals in non-governmental or community-based organisations typically also lack access to international, peer-reviewed journals and yet they are increasingly engaged in research or using information published in them.

Because of some of these problems encountered by researchers and teachers in this pre-open-access status quo, many have welcomed the advent of new approaches to publishing through open-access, with their potential to broaden access to new knowledge and insights to an international audience irrespective of socio-economic standing. The subsequent proliferation of open-access journals, however, has raised new challenges and questions, particularly when it comes to potential inequities in who can actually publish their work in such journals. I have noted increasing disenchantment among many observers and people working in the field who, in their experiences of open-access publishing to date, are left confused and concerned by the inequitable direction it appears to be going.

The first and foremost concern is that, as noted in the by Louise Finer, the cost of publication has effectively shifted from publisher to producer of knowledge or research. Most worrying is the advance payment necessary for authors to publish in open-access journals: typically either authors have to pay an advance fee for submitting an article to such a journal, or they have to pay a fee if their article is accepted. Such advance payments pose difficulties to many researchers, but put those in low and middle-income settings at a particular disadvantage. Some authors can include fees in research grants, if they have them, but this comes possibly at the expense of other research budget items. For many, the time period of research grants has finished when they are expected to pay the fees. In other cases, the funding organization may not allow the allocation of their funds to cover open-access fees. In some cases well-endowed universities subsidise researchers to pay these fees – but in my experience this is rarely the case in low and middle-income countries. Academic salaries in most low and middle income countries are certainly not high enough to allow academics to pay for the high costs of open-access publishing personally. The potential for inequities across countries and within countries between institutions (and even within institutions) immediately then becomes apparent. Moreover, to my knowledge there is rarely a sliding scale, allowing for this difference in the availability of resources for individual researchers.

Funders such as the Wellcome Trust (in the UK) and the National Institutes of Health (in the US) are committed to covering the costs necessary to make any research funded by these organisations open-access. My experience with Wellcome Trust funding at my institution is positive in that the Trust pays the publisher directly whenever an article is accepted. In this way, the researcher is insulated from having to make decisions about where to publish based on different costs and procedures, and can focus efforts on getting high quality research into a good journal. Moreover, the Wellcome Trust’s funding will include paying the fees to regular subscription journals to make particular articles open-access or to publishing in open-access journals. We must not forget, however, that most research taking place in low and middle income countries is not supported by such funders.

A further concern about the current state of open-access publishing is the lack of information or guidance to researchers about the best venues to publish in. Not a week passes that I do not receive an email about a new journal in my field inviting submissions and peer reviewers. We all know that open-access journals are proliferating, some probably for commercial motives, yet there is little guidance on how to assess their quality. Reviewing names on editorial boards is often not very informative if they are not known academics. Existing measures used to evaluate the quality of peer-reviewed journals such as the ‘impact factor’ , are inadequate, since they are based merely on the number of citations from articles published in them. Open-access journals may gain high impact factors because they are by their nature widely available and so articles published in them are often highly cited, but this tells us little about the quality of the article itself.

To conclude, I consider open-access to be a positive development in terms of making the most recent research available to a wide audience not dependent on one’s geographic position or socio-economic status. However, I am concerned that important questions remain, in particular about how accessible such publishing venues are for researchers from around the globe who may not be able to afford the often high associated costs. Thus while laudable in principle, I believe the current implementation of open-access publishing is flawed.

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We welcome responses to these blogs from publishers, authors and institutions.

As a researcher based in a middle income country, I would like to support the concerns raised in the blog by Louise Finer.

While many of us welcome the advent of open-access publication and the principles it represents, there are problems in the implementation of open-access publishing as it is currently evolving. Before turning to some of these problems, however, it should be said that the status quo before the advent of open-access publications also had many deficiencies and was inequitable both in access to and production of knowledge. This status quo has meant that, although most international, peer-reviewed journals published by commercial publishers had become available electronically, there is strict legal regulation (due to international intellectual property protection) over their availability and circulation. We have also become accustomed to a publishing model where, typically, researchers and reviewers who do the bulk of work for such journals are unpaid, yet subscription prices are high and rising often making them inaccessible. In the region where I work, and indeed in most low and middle-income countries, only the more well-endowed universities are able to afford journal subscriptions. This has led to a situation where only individuals working in institutions which can afford the high cost of international peer-reviewed journals (such as my own) have access to new research findings. And even for students in universities that do have journal subscriptions, they lose the privilege of access to such journals upon graduation. They therefore start their professional lives – whether in Lebanon or in other countries – having been exposed to the value of research and having become eager to do research themselves but restricted in their access to new research. Individuals in non-governmental or community-based organisations typically also lack access to international, peer-reviewed journals and yet they are increasingly engaged in research or using information published in them.

Because of some of these problems encountered by researchers and teachers in this pre-open-access status quo, many have welcomed the advent of new approaches to publishing through open-access, with their potential to broaden access to new knowledge and insights to an international audience irrespective of socio-economic standing. The subsequent proliferation of open-access journals, however, has raised new challenges and questions, particularly when it comes to potential inequities in who can actually publish their work in such journals. I have noted increasing disenchantment among many observers and people working in the field who, in their experiences of open-access publishing to date, are left confused and concerned by the inequitable direction it appears to be going.

The first and foremost concern is that, as noted in the blog by Louise Finer, the cost of publication has effectively shifted from publisher to producer of knowledge or research. Most worrying is the advance payment necessary for authors to publish in open-access journals: typically either authors have to pay an advance fee for submitting an article to such a journal, or they have to pay a fee if their article is accepted. Such advance payments pose difficulties to many researchers, but put those in low and middle-income settings at a particular disadvantage. Some authors can include fees in research grants, if they have them, but this comes possibly at the expense of other research budget items. For many, the time period of research grants has finished when they are expected to pay the fees. In other cases, the funding organization may not allow the allocation of their funds to cover open-access fees. In some cases well-endowed universities subsidise researchers to pay these fees – but in my experience this is rarely the case in low and middle-income countries. Academic salaries in most low and middle income countries are certainly not high enough to allow academics to pay for the high costs of open-access publishing personally. The potential for inequities across countries and within countries between institutions (and even within institutions) immediately then becomes apparent. Moreover, to my knowledge there is rarely a sliding scale, allowing for this difference in the availability of resources for individual researchers.

Funders such as the Wellcome Trust (in the UK) and the National Institutes of Health (in the US) are committed to covering the costs necessary to make any research funded by these organisations open-access. My experience with Wellcome Trust funding at my institution is positive in that the Trust pays the publisher directly whenever an article is accepted. In this way, the researcher is insulated from having to make decisions about where to publish based on different costs and procedures, and can focus efforts on getting high quality research into a good journal. Moreover, the Wellcome Trust’s funding will include paying the fees to regular subscription journals to make particular articles open-access or to publishing in open-access journals. We must not forget, however, that most research taking place in low and middle income countries is not supported by such funders.

A further concern about the current state of open-access publishing is the lack of information or guidance to researchers about the best venues to publish in. Not a week passes that I do not receive an email about a new journal in my field inviting submissions and peer reviewers. We all know that open-access journals are proliferating, some probably for commercial motives, yet there is little guidance on how to assess their quality. Reviewing names on editorial boards is often not very informative if they are not known academics. Existing measures used to evaluate the quality of peer-reviewed journals such as the ‘impact factor’ , are inadequate, since they are based merely on the number of citations from articles published in them. Open-access journals may gain high impact factors because they are by their nature widely available and so articles published in them are often highly cited, but this tells us little about the quality of the article itself.

To conclude, I consider open-access to be a positive development in terms of making the most recent research available to a wide audience not dependent on one’s geographic position or socio-economic status. However, I am concerned that important questions remain, in particular about how accessible such publishing venues are for researchers from around the globe who may not be able to afford the often high associated costs. Thus while laudable in principle, I believe the current implementation of open-access publishing is flawed.