Opposing the criminalisation of self-use of abortion pills

14/03/2016 Comments Off on Opposing the criminalisation of self-use of abortion pills

More officials in European governments seem to have discovered that women are buying MA pills over the internet and are having abortions outside their health systems. The immediate response to this is that these abortions are or should be “illegal”; indeed, they are illegal under the law in Ireland, the UK and Italy, if not also elsewhere. Two women were charged last year in Northern Ireland and are awaiting trial, three women are in prison in England (two for self-use of MA pills for very late abortions, one for selling them). Italy has just increased the fine for these abortions from €51 to €5,000-10,000. In Ireland the punishment is up to 14 years in prison. Women in the US have also faced criminal charges for this, and a case was heard in Australia as well, though in that instance the couple involved were let off.

Is the abortion rights movement ready for this new form of criminalisation of abortion to spread? I don’t think so, and I think we need to be talking about it quite urgently, especially in Europe.

A recent Guardian article about the extent of conscientious objection to abortion in Italy(http://www.theguardian.com/world/2016/mar/11/italian-gynaecologists-refuse-abortions-miscarriages), misses the point that for more than 90% of abortions, i.e. those in the first trimester, and indeed uncomplicated abortions up to 18-20 weeks, women don’t need a gynaecologist. Care from a trained nurse or midwife or other mid-level provider, with home use in the first trimester and in a day clinic in the second trimester are fine for uncomplicated abortions; WHO recommendations support this. It is primarily women with fetal anomalies and other later and complicated cases who need hospital-based abortion services under a gynaecologist, as these are understood today, and while it is crucial to provide and protect these services, they are not the model for all abortions.

Based on the evidence, we can push this a step further and say that for most women, abortion “services” should be offered mainly by pharmacies, and for the rest the health professionals who become abortion “providers” and the education and training they receive needs to change a lot. Pro-choice gynaecologists should be among those to take the lead in arguing this as they have the standing to be listened to.

We need to start arguing that medical abortion pills are safe enough that they should be as readily available for early abortions as emergency contraception is for the morning after. And we need to be informing women of this because most women probably don’t know it. Not the way we know it.

Do we even have a consensus on these points among ourselves? I’m not sure. But what I hope we all do agree on is that criminalising the self-use of MA pills is happening and must be opposed, and I believe urgently.

Most of the mainstream media articles on women self-inducing abortions quote one official or other that the pills are dangerous if used without the supervision of a health professional. The article about Italy is an example. There is a lot of evidence to the contrary that needs to be shared as widely as possible.

Framework Convention on Global Health (FCGH) – a blog in response to the May 18 Geneva meeting minutes

24/09/2013 Comments Off on Framework Convention on Global Health (FCGH) – a blog in response to the May 18 Geneva meeting minutes

A blog by Marge Berer, Editor Reproductive Health Matters. Originally posted on the blog of JALI – the Joint Action and Learning Initiative on National and Global Responsibilities for Health

I asked JALI if I could write a blog after I had read the minutes of the May 18 meeting in Geneva on the way forward for an FCGH,  to raise some issues that I’ve been confronting in the seemingly endless consultations and statements circulating on the internet on the post-2015 world – to do with what an MDG replacement would look like, whether or not universal health coverage as currently conceived is the answer to how to address health, and whether and where my issues of sexual and reproductive health and rights might fit into the “Sustainable Development Goals”, the most likely successor to the MDGs, when they have had such short shrift in the MDGs.

I was particularly struck by the paragraph on the two animating principles of a Framework Convention on Global Health mentioned in the minutes, that is, ‘global health equity (within and between countries) – “global health with justice,” as offered by Larry Gostin – and the right to health… setting clear standards to make it more concrete, measurable, and enforceable… addressing global governance for health… shifting international law towards health. It would ensure for all people the conditions required for health, including health care, public health, and social determinants of health, setting standards and establishing a national and global financing framework to enable universal access to and coverage of health care and public health measures (e.g., clean water, sufficient nutritious food)… directly address domestic inequities…[and] promoting Health in All Policies.’ (pp.2-3)

Just as people in the meeting raised the fact that some participants in the FCGH process required more explicit attention, e.g. health workers and health worker unions, as did some issues, e.g. mental health, I would like to raise three aspects that I think need to be part of the FCGH discussions:

i. Gender issues – that is, the differences between men and women in their health needs, their access to health and health care, and the inequities in that differential access. Gender issues in relation to health are crucial to any convention. There has been a lot of work by women’s health advocates on gender issues in relation to women’s health but far less work by either men or women on gender issues in relation to men’s health. In the same ways as girls’ and women’s health issues were at one time almost invisible in the previous century, attention to boys’ and men’s health issues has not been developed in the past 30 years, in spite of the growing attention to women’s health issues and wide-ranging work on gender, both in academia, by the women’s health movement and even in WHO. In a recent paper I was considering for publication, for example, it was said that gender-based violence against women was the most common form of violence, when in fact men experience far more violence globally overall, but between each other, whereas women experience violence mostly from men. Thus, work is needed on how to address gender issues within an FCGH in relation to the right to health, the social determinants of health, health financing, etc, and how this might be approached needs much more thought and consideration.
ii. Religious, political and “cultural” opposition to what an FCGH would stand for, being used most vocally today to justify why access to crucial aspects of health and health care related to sexuality and reproduction are being withheld and denied, and many sexual and reproductive rights condemned and criminalised. Underlying this opposition are two forms of hate: misogyny and hatred of any form of sexuality that is not heterosexual and heteronormative.

One of the reasons I support a Convention is that it would give greater weight to all these issues by requiring not only non-discrimination and equality, but also regular examination, analysis and critique of country programmes, along with official recommendations for policy and programmes, and demands for accountability and action through interpretation of the implementation of the convention. We are beginning to see such a framework making a difference in relation to sexual and reproductive rights issues, particularly via the work of CEDAW. So I recommend studying CEDAW’s history, functions, and procedures particularly and how they might be applied more broadly across health. I would be interested in being involved in this in the future.

iii. The process of developing the successor to the MDGs may cut out the few specific aspects of health and health care that were allowed into MDG 5, where they were mostly reduced to their lowest common denominator and stripped of their complexity, e.g. universal access to reproductive health was a late add-in to MDG 5, which never moved beyond superficial attention to a few aspects of reducing maternal mortality, diluted heavily by tacking newborns, infants and children onto “maternal” health, and omitting the great majority of interlinked sexual and reproductive health problems.

Universal health coverage in my opinion may also succeed in shortcutting and eliminating the “controversial issues” in whatever is included under a “unified health goal” post-2015, and it may also make support for addressing specific aspects of health equally or even more difficult. Having devoted two recent issues of Reproductive Health Matters to privatisation in sexual and reproductive health services, where articles provided evidence of a resulting increase in inequity of access to health care among the 4th and 5th socioeconomic quintiles of many African and Asian countries, I am worried that the health goal that is eventually agreed is likely to be biased one way or another towards consumerism, commercialisation and privatisation of health and health services, and their financial underpinnings such as health insurance. I am very uncertain of the value of what has emerged so far as regards universal coverage from WHO, given the pressure on the agency from the World Bank, big pharma, world trade policies, and the influence of private/foundation donors, when measured against what we would like to see as the basis for the Framework Convention on Global Health.

 

The Brazilian government pays compensation for a maternal death taken up by CEDAW – a decision that has global implications

14/09/2012 Comments Off on The Brazilian government pays compensation for a maternal death taken up by CEDAW – a decision that has global implications

Lisa Hallgarten, RHM

The Brazilian government has agreed to pay compensation for the death of a pregnant woman in 2002. The decision could have implications for governments around the world where women are dying from preventable deaths in pregnancy, childbirth and abortion. The Brazilian government’s move follows landmark decisions by the Committee on the Elimination of Discrimination against Women (CEDAW) in Brazil and Peru – reported in Reproductive Health Matters. CEDAW confirmed that all states have a human rights obligation to: guarantee good quality maternal health care; guarantee access to abortion when a woman’s mental or physical health is threatened by continuation of her pregnancy; and decriminalise abortion when the pregnancy results from rape or abuse.

The case of of Alyne da Silva Pimentel v. Brazil was taken up by CEDAW in 2011. Alyne died following a stillbirth towards the end of her second trimester of pregnancy as a result of misdiagnosis, inadequate treatment in her local health centre, failure of the centre to refer her for timely emergency obstetric care and inadequate care when she was finally referred. CEDAW found that she was a victim of discrimination because she was a woman, poor and of African descent. Following the CEDAW Committee’s recommendations, the Brazilian government has agreed to pay compensation for Alyne’s death in childbirth, and is to set up an inter-ministerial enquiry into where responsibility lies for the chain of events that result in a maternal death. It also plans to organise a seminar on the issue for lawyers and health professionals.

In the case of L.C. v. Peru, a young girl had been repeatedly raped by different men in her neighbourhood over a period of four years. At the age of 13 she learned that she was pregnant and made a suicide attempt which failed, but left her at risk of paralysis and in urgent need of spinal surgery. She was refused the surgery she needed because she was pregnant, and was also refused an abortion. Three months later she miscarried and doctors agreed to perform the surgery. Unfortunately the delay meant the intervention was unsuccessful and L.C. is now quadriplegic. Peruvian law already permits abortion in cases where a woman’s health or life is at risk. CEDAW ruled that access to abortion in these cases should be guaranteed.

CEDAW’s findings come in the context of legal and civil actions around the world aimed at making governments accountable for women’s health and lives in pregnancy, childbirth and abortion. We hope that the announcement from Brazil that it will act on CEDAW’s recommendations may encourage Peru to do so too, and will  help to reinforce the fundamental principle that women’s rights are human rights.

Other cases highlighted in RHM

Alyne’s case and the negligent, callous and discriminatory treatment she experienced, has echoes in stories we have published from all over the world including the testimony of a doctor in a sub-Saharan African country on this blog. Papers in May’s issue of Reproductive Health Matters demonstrate that failure to provide good quality, equitable and accessible maternal health care is widespread. Increasingly however, lawyers, families and health professionals have had some success in holding their governments and health services to account.

In India an investigation into maternal deaths in Madhya Pradesh documented lack of accountability, and discrimination against poor women, particularly tribal women. However, the authors report that since presenting the report some of their recommendations have been taken up. In another article from India authors explore the successful legal case made for compensation and accountability for the death of Shanti Dev in Haryana State.

Another article reports on opportunities for progress that could be learned from the success of HIV activism in sub-Saharan Africa where health professionals and civil society activists have formed alliances to demand constitutional rights to health care for people living with HIV. A recent attempt by health activists in Uganda to use the courts to establish the constitutional rights of women to quality maternal health care failed, but the NGOs involved have promised to appeal…watch this space.

Read the full editorial of RHM’s recent issue Maternal mortality or women’s health: time for action

Race, Reproductive Politics and Reproductive Health Care in the Contemporary United States

20/07/2012 Comments Off on Race, Reproductive Politics and Reproductive Health Care in the Contemporary United States

This editorial from the journal Contraception offers an important analysis of population and family planning policy in the USA, both in the context of current politics and also from history, starting as far back as 100 years ago.

Carole Joffe, Willie J. Parker

From: Contraception [Editorial] July 2012 reprinted as a blog with kind permission of Carole Joffe

To paraphrase Leo Tolstoy, who famously wrote that all unhappy families are unhappy in their own way, we can say that all nations confront the thorny issue of demographics, but each in its own, typically controversial, way. Various European countries, for example, have anxieties about a “demographic winter,” which is a below replacement birth rate of the native population, which has led to corresponding fears about rising birth rates among Muslim immigrants. China, driven by worries about overpopulation, has instituted coercive reproductive policies that many observers find unacceptably harsh. The United States, a country marked by extreme stratification on both racial and economic grounds, is a particularly interesting case to consider from a demographic lens because there has been a history both of targeting the birth rates of people of color and at the same time deep political divisions about the provision of reproductive health services — particularly abortion but increasingly, as the current election season reveals, contraception as well.

We, a sociologist and physician, respectively, write here of our dismay about the contemporary state of reproductive politics in the United States and particularly the cynical manipulation of racial themes by the opponents of abortion and birth control. However, we are acutely aware of the mixed legacy of the United States with respect to demographic issues. To name but a few examples, in 1905, President Theodore Roosevelt warned of “race suicide” because of his concern about falling birth rates among white Anglo-Saxon women and the higher rates among immigrants.1 In the 1927 Supreme Court case, Buck v Bell, the Court upheld a statute instituting compulsory sterilization of the unfit, including the mentally retarded, “for the protection and health of the state”.2 In the 1960s, impoverished African-American and Latina women, along with some poor whites, were subjected to coerced sterilizations, often without these women fully understanding to what they had ostensibly agreed.3 When the first federally funded family planning centers were established in the early 1970s, as a result of the passage of Title X, they were disproportionately located in African-American communities, although the language of the legislation did not mention race but rather the income status of the intended recipients.4

Co-existing with these events, however, has been a longstanding reproductive freedom movement in the United States, made up of clinicians and lay activists alike. Starting in the early 20th century, doctors and nurses, along with lay allies, fought for the legalization of first, birth control, and, later, abortion, seeing the particular damage done to the most vulnerable women in the absence of such services. In the 1960s and 1970s, feminist health activists raised an outcry about the sterilization abuses mentioned above; indeed, among the most prominent of the reproductive rights organizations to emerge from the “second wave” feminism of that era was CARASA, the Committee for Abortion Rights and Against Sterilization Abuse, providing a template for the principle that abortion rights should ideally be considered in a broader context that includes the right to have children.5 That generation of feminist activists also severely criticized the then-common practice of testing new contraceptive methods on Third World women. Today, there are numerous reproductive rights/reproductive justice groups hard at work in the United States, a number of them specifically concerned with the situation of women of color.

In short, this very brief recapitulation of reproductive struggles in the United States reveals the truism that the world of sexual and reproductive health services is a complex terrain, always containing both liberatory and coercive possibilities, and always with particular implications for people of color in a white-dominated society. But with respect to present-day conflicts, no figure’s legacy has been more contested than that of Margaret Sanger, the founder of the organization that eventually became Planned Parenthood. Anti-abortion forces for years have accused Sanger of being a racist and a eugenicist. Currently, these groups have pounced upon the high rate of abortion within the African-American community — black women have abortions at nearly four times the rate of white women — and have joined forces with some conservative groups within that community to mount a vigorous campaign against Planned Parenthood in particular and abortion provision more generally. Starting in Atlanta, and spreading to other cities, these groups have sponsored controversial billboards — some proclaiming that “black children are an endangered species” and others comparing abortion to slavery.

As Ellen Chesler, Sanger’s premier biographer, has argued, such accusations are a distortion of Sanger’s record.6 Although Sanger did receive some support from eugenicist organizations (at a time when eugenics was a far more mainstream movement than it is currently), her record cannot be construed as “racist.” Among her supporters were numerous black ministers, leading African-American intellectuals such as W.E.B. Dubois, and prominent community leaders such as Mary McLeod Bethune, founder of the National Council for Negro Women. In 1966, when Dr. Martin Luther King accepted the first Margaret Sanger award from Planned Parenthood, he praised Sanger for “her courage and vision,” comparing her struggle for birth control to the civil rights movement. One of the most effective critiques of the billboard campaign, and against the larger agenda of demonizing Planned Parenthood, has come from Sistersong, a coalition of reproductive justice groups of women of color. As Loretta Ross, the executive director of the group told the New York Times, “The reason we have so many Planned Parenthoods in the black community is because leaders in the black community in the ‘20s and ’30s went to Margaret Sanger and asked for them. Controlling our fertility was part of our uplift out of poverty strategy, and it still works”.7

This manipulation of the history of race and reproduction by those involved in the billboard campaigns and similar efforts obscures the contemporary facts of life faced by the most vulnerable black women. These women experience high rates of unintended pregnancy, low use of the most effective forms of contraception, deep poverty, inadequate educational opportunities, unacceptable levels of intimate partner violence and, very often, lack of support from their churches. It should come as no surprise that these same women would have the highest rates of abortion in this country. Given the conditions, these women need — among many other services — access to comprehensive health care that includes both family planning and abortion. Yet, abortion has long been excluded from most mainstream health care institutions and sources of public funding, and during the current political season, we have watched with dismay the severe attacks on contraceptive coverage as well. The isolation of abortion, in particular, from the rest of health care has contributed to its stigmatization and has helped the development of conspiracy theories, such as we see in the billboard campaign. We decry the inflammatory, false rhetoric of “black genocide” that has been used in this campaign by anti-abortion extremists, and we are hardly the first to point to the hypocrisy of those who oppose contraception and abortion, yet just as fervently oppose any spending for social services.

One of us (WP), speaking from my perspective as a member of the African American community and as a women’s health provider, asserts that this attempt to manipulate my community is made possible by our unresolved issues regarding gender roles and sexuality in a modern context. The failure of our community to promote the agency of our mothers, sisters and partners, and to deal forthrightly with sexual matters, leaves us treating abortion and HIV-related issues as “open secrets.” This evasion results in exorbitant rates for both. To truly confront these issues, our community desperately needs medically accurate sexuality education, improved health literacy and a constructive engagement of religious and spiritual leaders, given the central importance of religion in the African-American community. This type of empowerment effort towards shared reproductive health responsibility is the only effective rebuttal to the mischief occurring with race and reproduction in our community. To paraphrase Dr. King, just as individual wealth is always a function of the commonwealth, thus it too holds true that compromising the reproductive health and rights of individual black women results in jeopardizing the collective well-being of black communities.

If to know is to become responsible, my awareness of black women’s unmet reproductive health needs requires me to provide family planning and abortion care to those most in demand for them. Doing so represents a dual sense of responsibility that I feel as both a women’s health provider and as a member of the African-American community. I join with those in my community who have articulated a vision of reproductive justice, defined as creating a society that enables all women and families to have the children they want, the resources needed to raise them, and the ability to prevent or end the pregnancies that they do not want. I call on my fellow health care providers, of all races, to trust women to make the good and tough decisions about when and whether to expand their families. A fundamental respect for fairness necessitates it, and a respect for human rights demands it.

In conclusion, as already noted, we write in a period of unprecedented political attack on women’s health issues — not just abortion, but also contraception and a range of other reproductive health services. Even the seemingly long settled issue of the importance of programs to combat domestic violence is now being resisted by conservative forces.8 This “war on women,” as it has come to be known, has galvanized a countermovement of health activists, both women and men, who have effectively and creatively protested these developments in a variety of ways. We are greatly heartened by this mobilization, although its eventual impact on elections and restrictive measures is unclear at this time. We close by reminding our readers of what is perhaps obvious: the stakes in this “war” are inevitably the highest for the most vulnerable in our society — those poor women of color about whom we have written in this editorial.

Carole Joffe
Advancing New Standards in Reproductive Health
Bixby Center for Global Reproductive Health
University of California, San Francisco
Oakland, CA

Willie J. Parker
Board member
Physicians for Reproductive Choice and Health
New York, NY

  1. Roosevelt T. On American Motherhood. Available at http://www.nationalcenter.org/TRooseveltMotherhood.html (accessed July 20, 2012).
  2. Buck v. Bell, 274 U.S. 200 (1927). Available at http://www.oyez.org/cases/1901-1939/1926/1926_292 (accessed July 20, 2012)
  3. Schoen J. Choice and coercion: birth control, sterilization, and abortion in public health and welfare. Chapel Hill: University of N. Carolina Press; 2005;
  4. Gordon L. In: The moral property of women: a history of birth control politics in America. Urbana, IL: University of Illinois Press; 2002;p. 289–291
  5. Petchesky R. In: Abortion and woman’s choice: the state, sexuality and reproductive freedom. Boston: Northeastern University Press; 1990;p. 392
  6. Chesler E. Was Planned Parenthood’s founder racist?. Salon. 2012;Nov 2. Available at http://www.salon.com/writer/ellen_chesler/(accessed July 20, 2012).
  7. Dewans S. Antiabortion ads split Atlanta. New York Times. 2012;Feb 5. Available at http://www.nytimes.com/2010/02/06/us/06abortion.html?scp=1&sq=Shaila%20Dewan%20Margaret%20Sanger&st=cse (accessed July 20, 2012).
  8. Joffe C. All common ground lost: the right’s opposition to the Violence Against Women Act. Rhrealitycheck.org. Available at http://www.rhrealitycheck.org/article/2012/03/16/all-common-ground-lost-rights-opposition-to-violence-against-women-act (accessed July 20, 2012).

Family planning and safe, legal abortion go hand in hand

19/07/2012 Comments Off on Family planning and safe, legal abortion go hand in hand

Marge Berer

Editor, Reproductive Health Matters

One in three women in the UK will have an abortion in her lifetime, most of whom will have been using contraception of some kind. Yet since as long ago as the late 1930s, there has been a split in the UK between those who insisted on promoting contraception on its own because they thought abortion was too controversial and would hold back acceptance of family planning, and those who insisted that the two go hand in hand. This split exists in many countries, not just the UK, and also within many organisations with a large membership in different countries, such as the International Planned Parenthood Federation (IPPF). It is reflected most recently in a comparison of the list of 600 groups and individuals who have endorsed the International Campaign for Women’s Right to Safe Abortion this year, and the 1300 that signed a letter circulated by the IPPF supporting the Family Planning Initiative – very different groups are on those lists. Yet all of them support the right to control fertility.

In 1994, the ICPD Programme of Action, a consensus document on the integration of sexual and reproductive health and rights, was only able to be passed if it included a “compromise” clause that called for abortion to be safe only if it was legal. This compromise was and remains a violation of public health principles and women’s human rights. ICPD failed to condemn the often 19th century, often colonial laws on abortion still in place in the criminal code in many countries. However, the Programme of Action did recognise that unsafe abortion was a major public health problem, one which to this day still affects some 22 million women every year, among whom 5 million end up in hospital with complications annually and tens of thousands die (WHO, Guttmacher). And young women, whom everyone wants to be  seen to be supporting these days, are in fact most at risk of unsafe abortion and also have the least access to contraception (Shah & Åhman, RHM, May 2012).

The answer is not to promote contraception in order to reduce unsafe abortion, as the FP Summit did. The answer is to promote contraception to reduce unwanted pregnancy and provide safe abortion to every woman who finds herself with an unwanted pregnancy. That is the way to make unsafe abortion history. Abortion will not go away unless men and women stop having sex with each other or everyone is sterilised. So forget it! The growing number of countries in both the north and south, east and west, where there is 60-80% contraceptive prevalence proves that. Research shows that women and men take up contraception in large numbers if they feel they have the right to control their fertility and have access to the means to do so. There is a huge need for information, because every new generation of young women and men will know nothing about contraception or abortion unless they have access to this information. But there is no need for “demand creation”, a retrograde concept which implies lack of interest. The steadily falling fertility rate globally, falling since the 1970s, proves that, and in every country, abortion is in there, safe or unsafe, reducing the number of births. Forty-four million abortions globally and hundreds of millions of people using contraception and sterilisation prove the huge demand for the means of fertility control. “Unmet need” is more than just lack of knowledge or interest on the part of the women and men who aren’t using contraception, or using it erratically or unsuccessfully.

Women seek an abortion if they have an unwanted pregnancy, legal and safe or not, because it’s too late for contraception. There is no split between contraception and abortion from women’s perspective, they are two sides of the same coin. Even so, many of the biggest supporters of “family planning” refuse to support women’s need for safe, legal abortion. Even worse, they always talk about abortion in negative terms. They mention it along with STIs, as if it were a disease, or treat it as an annoying problem that they wish would go away, and consider it inferior to use of contraception. They even claim that use of contraception will (or should) make it go away. But this is about the realities of people’s sex lives and how sex happens, not just about well-thought-out, planned-in-advance decisions about family formation. Many pregnancies are started without any forethought at all, and all too often as one of the consequences of sexual pressure and coercion.

Campaigns for women’s right to safe, legal abortion have been going on for at least 100 years. Many of us involved in these campaigns are still seen as annoying by people who are supposed to be our colleagues. We’re told it’s sensitive, controversial, difficult, it can’t be put on the agenda, including in the FP Summit. At the same time, many of us who are fighting for abortion rights stopped supporting “family planning” years ago, because of what happened in the past, when coercive programmes put many people off “family planning” and gave it a bad name. Some family planning supporters have blamed ICPD for the neglect of family planning, because it placed family planning in a wider context. But as Gita Sen said at the Summit, ICPD in fact sought to rehabilitate family planning and restore its good name, while the barriers to safe abortion were left in place.

Today’s supporters of family planning would like everyone to forget the coercive programmes of the past, which were target-based. But they may yet become target-based again because of “results-based financing”. So let’s not confuse opposition to coercive family planning policies with being anti-family planning. Yet, it is absolutely true that provision of contraception has been neglected in recent years – and yes, this neglect must stop. At the same time, neglect also characterises how women’s unmet need for safe abortion is treated. What needs to change is that both forms of unmet need should be taken into account – together – starting with donor and national government policies.

For example, although DFID’s development aid policy has long been to fund both family planning services and abortion services, in their roll-out of these policies, funding for family planning is (I am told) separated from funding for safe abortion. That is, it is managed by different people and in different programmes within DFID and in the recipient countries, and these different people may not work closely together or know what each other are doing. Yet DFID did not see a problem in agreeing to a family planning initiative in which funding for abortion is excluded. They fund abortions anyway, they say, so what’s the problem? The problem is that separating abortion from family planning at the programmatic level allows some countries to keep abortion legally restricted and not take responsibility for unsafe abortion.

Then there’s the US, where support for family planning by USAID has been the highest in the world for many years now, while safe abortion services are not funded by them at all. Since ICPD, however, the US has funded post-abortion care, which was invented at ICPD as a way to save women’s lives who had had an unsafe abortion. Unfortunately, the evidence that post-abortion care has in fact saved many women’s lives since ICPD is sparse and not compelling. Yes, the number of deaths from complications of unsafe abortion has fallen a lot, but this may be due to self-medication with misoprostol replacing life-threatening methods.

In fact, once ICPD was over, this so-called post-abortion care should have been rejected as unethical, because it allows harm to be done unchallenged and forces health care providers to clean up the mess without the support of the law. Under US aid policy, even countries where abortion is legal who tried to use USAID funds for safe abortions as well as for contraception and sterilisation, in integrated programmes, had their “family planning” funding stopped. Research has now shown that this leads to higher rates of unwanted pregnancies and abortions in those very same countries, proving how illogical such a policy is/was. Will that evidence, published only recently, lead to a change in USAID policy? Unlikely. Too sensitive. And meanwhile, a violent and fanatical anti-abortion movement flourishes in the US, where some of the most punitive and misogynistic barriers to safe abortion are being implemented with near impunity, in one state after another.

The anti-abortion movement is also anti-family planning. For years, they were very circumspect about this as they feared, quite rightly, that it would lose them support. But the current Vatican has helped to bring anti-abortion opposition to contraception and assisted conception out in the open again. This is evidenced in campaigns to ban emergency contraception and assert conscientious objection to providing contraceptives, e.g. by pharmacists. But still, many in the family planning movement do not support the right to safe abortion.

In light of the Family Planning Summit, it is a good time for abortion rights activists who have ignored family planning to link up with the family planning movement, and help to ensure that services have a rights-based approach. It is also a good time for all family planning colleagues to support the right to safe, legal abortion alongside the right to access contraception and sterilisation – and talk about abortion as a legitimate part of fertility control, a solution to unwanted pregnancy, a public health necessity for women, and a legitimate health care service. All of us should acknowledge the huge unmet need for safe, legal abortion services as well as for contraception and sterilisation services, and ensure that they are provided – and funded – together.

Many effective contraceptive methods, condoms, two types of emergency contraceptive pill and two very safe methods of early abortion – all on the WHO essential medicines list – can and should be provided at primary health care level. This includes medical abortion pills and manual vacuum aspiration for abortions up to 9-10 weeks. Some of these can even be provided during home visits by community-based health workers – the pill, condoms, injectables, emergency contraceptive pills and medical abortion pills for early abortions – as long as there are nurses, nurse-midwives or other mid-level providers who have been trained to do so. The evidence is there– this is all safe and effective. Moreover, the legitimate sort of post-abortion care, i.e. the kind that happens after safe abortions, needs to include information about and provision of contraception, just as post-partum care ought to do. So, even programmatically and clinically, the integration of family planning and abortion makes more sense than ever.

The morning after: the beginnings of an assessment of the FP Summit

16/07/2012 Comments Off on The morning after: the beginnings of an assessment of the FP Summit

Marge Berer
Editor, Reproductive Health Matters

13 July 2012

From a communications point of view, the FP Summit was a raving success. Newspapers, TV and radio all over the world covered it. Around the globe everyone reached by the media heard how wonderful family planning is and how neglected it has been, the Lancet launched a special edition , Guttmacher and others released facts and figures showing the extent of unmet need. Across the women’s health movement the listserves, Facebook and Twitter were full of it. All in all, the day – and many of the messages it gave birth to – had enthusiastic, even missionary, overtones.

On the absolutely fabulous side, Melinda Gates’ challenge to the Pope to acknowledge that contraception is ‘not controversial’ even amongst Catholic women, is likely to rock the foundations of the Vatican’s whole policy on abstinence, condoms and contraception from the grassroots of the Catholic church up. It was God’s gift to Catholics for Choice, who will be promoting Condoms-for-Life and safer sex at the upcoming AIDS conference later this month.

Also on the plus side, there were representatives of governments and many, many others who are making progressive change happen in their countries, and who spoke out about it. These are people who can make a big difference when they get home who did support comprehensive sexual and reproductive health and rights from the podium and the floor of the meeting, and who insisted that family planning services can only be provided within that wider remit. There were people who needed to learn what it was all about, some of whom were too young to have lived the history, but who came with strong pro-choice views.

The media exposure of the value of family planning has a huge potential for good, because it will have reached people who didn’t know family planning existed or whether it’s good for them and safe, and others who have never had a chance to talk about these matters with others. It will also have put fertility control as a public good on the map around the world. And hopefully it will spur those with expertise in sexuality and reproduction to start talking about what they know, and what is and is not true amongst all the hoopla – and to assert that the power of money must not be allowed to take precedence over public health values and human rights principles, or the values of knowledge and truth.

On the oh-God-help-us-no-no-no side, though, Melinda Gates anointed herself as the new saviour of women’s and children’s health, and the press ate it up in both pictures and words. Some of the best people in the field of sexual and reproductive health, were unexpectedly uncritical, singing the praises of this wonderful opportunity. Perhaps not surprising given the historical shortfall in funding for family planning.

A golden moment, the kind that big money and a Tory government are at home in, stage-managed by a slick public relations company called McKinsey (who describe themselves as “the trusted advisor and counsellor to many of the world’s most influential businesses and institutions”). With big pharma, having abandoned contraceptives for many years, talking about the opportunity (“70% of this market is under-served”) to make a profit from family planning needs and then give some of it back to women – as a charitable gift. Patting each other on the back for being so wonderful as to finally have recognised that women have health needs they can exploit. A truly Hollywood event, except this is not entertainment. This is women’s lives.

This golden moment, which had to happen mainly because so many governments have failed to take responsibility for the public health needs of their citizens, for maternal health, family planning, abortion, sexual health, in the only equitable manner that works – by providing publicly funded, well-resourced services.

It was a day that showed the world it was possible for one very well-meaning woman, backed by the power and money of her husband, to direct global policy and claim ownership of the provision of family planning to 120 million women and at the same time, to disparage and stigmatise women’s need for abortion to the entire world – and get away with it without being challenged. She had the courage to challenge the Pope. It is a shame that a summit attended by many of the world’s experts on these subjects could not emulate her bravery and challenge her in return.

She was not the only one who got away with it. The Summit also gave the podium to and applauded politicians from countries where millions of women have the very unmet need for contraception in whose name this Summit was called: women who are still dying from unsafe abortions because their governments are too cowardly to make abortion legal and safe; and women who are dying from complications of pregnancies because they have no access to life-saving maternity care. Countries that since the 1960s have received hundreds of millions if not billions of US dollars for family planning, which have as good as disappeared, or been squandered and misspent.

It included representatives of the very same private sectors whose services and prices for contraceptive methods and safe abortions remain inaccessible to and unaffordable for many in the world’s population who need them, especially young women and men. And not only in low- and middle-income countries, but also in the United States, a country whose health industry has made life hell for Barack Obama for trying to make health care even a little bit more affordable, excluding abortion of course, for millions of disenfranchised people. The United States – a country that has the biggest and most violent and aggressive anti-abortion movement on earth, second only to the Vatican, and some of the highest unintended pregnancy rates in the developed world, especially among poor women.

It was addressed by the Prime Minister of the UK, the Right Honourable David Cameron, who got a standing ovation for a speech about the importance of empowering women, a speech that stank of hypocrisy. A Prime Minister who is responsible for indefensible, swingeing spending cuts that are adversely affecting women, young people and children above all, including cuts in family planning, sexual health services and welfare, at a time when it has never before cost so much to raise a family. Whose Secretary of State for Health is selling off our National Health Service piece by piece, who has wasted public time and at least £1 million in public money harassing some of the real heroes of women’s rights, that is, abortion service providers, for no credible reason. Whose Minister for Public Health put an anti-abortion group on the government’s sexual health advisory group “for the sake of balance” and to propitiate anti-abortion fanatics in Parliament – a Minister who described abortion as a “sensitive” issue, after 45 years of safe, legal abortions (except for women in Northern Ireland, of course).

And now it’s the morning after. How to go on from here and engage in what will happen? It’s a pity about Melinda Gates’ prejudices against abortion. I hope she will reconsider them because it would make her a far more credible ambassador for this cause which, after all, does not belong to her.

Making change happen is in the air

13/07/2012 Comments Off on Making change happen is in the air

Marge Berer

Editor, Reproductive Health Matters

Below, are excerpts from my editorial in RHM 20(39) May 2012. This issue is about reducing maternal mortality, but the more I reflected on it the more I realised it had implications for this week’s summit on family planning.

Making change happen is in the air, from the UN Secretary-General down to the most remote village… Yet, in certain ways, the world is moving backwards when it comes to dealing with women and pregnancy. Simone Diniz calls it a return to “materno-infantilism” – treating pregnant women like children who need looking after… Today, in much of the literature, all pregnant women are called “mothers” whether they’ve ever had a baby or not. Yet pregnancy has more than one outcome and is not only about women who “deliver”. It’s also about women who experience miscarriages, stillbirths, infant deaths, lack of access to contraception, unwanted pregnancies, unsafe abortions, and lifelong obstetric, reproductive and sexual morbidity. Yet these are nearly invisible in PMNCH these days, and safe abortion – an integral part of women’s right to decide the number and spacing of their children – may be made invisible in the new Family Planning Initiative as well…

The papers [in this journal issue] show that some countries are making serious efforts at strengthening and improving their health systems in relation to reproductive health care and maternity services. Based on data that show who is dying and why, they are making policy and programme changes, such as low-cost delivery services for poor and migrant women, opening new obstetric emergency care and referral centres in hospitals, training more health professionals, and providing health education for women, as in Shanghai (Du et al)…

Others are strengthening the whole public health system, especially in rural areas where most poor women live, ensuring better leadership and governance, increasing health workforce skills, supporting community-based health insurance, and increasing contraceptive services, as in Rwanda (Bucagu et al). They’re promoting peace, stability, economic growth, poverty reduction, improved primary education, better roads and communications, access to information on health and health services, and making health care free of cost for the poor, as in Cambodia (Liljestrand & Sambath)…

In contrast, in some countries, appalling, chaotic, uneven, negligent and abusive situations persist. Among the 22 million women each year who have unsafe abortions, adolescents suffer the most from complications and have the highest unmet need for contraception (Shah & Åhman). Custom, lack of perceived need, distance, lack of transport, lack of permission from husbands, cost, unwillingness to see a male doctor are still preventing women from seeking antenatal and delivery care, e.g. in northern Nigeria (Doctor et al), but in many places, these services barely exist anyway…

In the poorest of countries, women may have more pressing health needs even than for maternity care, e.g. in Haiti, where women identified access to any affordable health care, potable water, enough food to eat, any employment, sanitation and education as their most crucial problems (Peragallo Urrutia et al)…

Even more broadly, lack of national commitment has been identified as critical in 33 sub-Saharan African countries, as well as very low levels of public financing for health and health services (let alone maternity services), poor coordination between key stakeholders and partners, poorly functioning health systems with poor logistics for supply, distribution and management of essential medicines, family planning commodities, and equipment, and a chronic shortage of skilled health professionals (Ekechi et al).

In several South Asian countries, cash is being given to pregnant women to deliver in facilities, but some studies are finding, e.g. in India, that when women arrive, there is limited or no antenatal care, no birth attendants with midwifery skills, no emergency obstetric care in obvious cases of need, and referrals that never result in treatment (Subha Sri et al). And now, these same women have a sense of entitlement, and they are protesting.

Several governments in Latin America may be embarrassed to learn that their levels of budget transparency in spending on specific aspects of maternity care were found to be very low, and that they need better budgeting modalities, better health information systems and guidelines on how they might better capture data on expenditure, in order to track and plan local and national progress (Malajovich et al). Similarly, an assessment of cash transfer and voucher schemes designed to stimulate demand for services and reduce cost barriers to maternity care found increased use of maternity services in several south Asian countries, but also a need for more efficient operational management, financial transparency, plans for sustainability, evidence of equity and, above all, proven impact on quality of care and maternal mortality and morbidity (Jehan et al).

The papers [in this journal issue] describe a range of models for advocacy and taking action to expose violations of human rights, poor public health practices, absence of monitoring and regulation, failure to ensure national accountability for sexual and reproductive rights and to provide remedies and redress in the event of violations (Kismödi et al).

full editorial

Trends in maternal mortality 1990-2010: latest data

18/06/2012 Comments Off on Trends in maternal mortality 1990-2010: latest data

by Marge Berer

Editor Reproductive Health Matters

Thanks to the Millennium Development Goals and much work on the part of the UN, WHO, many governments and NGOs globally and nationally, the press and media are now highly attuned to what is happening as regards maternal mortality. An announcement by WHO on behalf of the United Nations of the latest global estimates, published in May 2012, showed that the trend in maternal deaths appears to be falling overall, and resulted in many newspaper articles sharing this very good news. The global data were as follows:

  • The number of women dying due to complications of pregnancy, childbirth and unsafe abortion decreased from 543,000 in 1990 to 358,000 in 2008, and 287,000 in 2010.

This excellent news masks the fact that there has been a lot of change in some countries and virtually none in others. Here are some of the details of those differences, taken from the report:

  • Deaths are falling quickly in East Asia but the reduction is attributed largely to China.
  • Southern African countries have seen the beginnings of a reversal, but sub-Saharan Africa (56%) and southern Asia (29%) accounted for 85% of the global burden in 2010.
  • India (19%) and Nigeria (14%) alone accounted for a third of deaths globally.
  • 40 countries (20 % of the total number of countries) still have maternal mortality ratios greater than 300 deaths per 100,000 live births.
  • Countries with the highest maternal mortality ratios were: Chad, Somalia, Sierra Leone, Central African Republic, Burundi, Guinea-Bissau, Liberia, Sudan, Cameroon, and Nigeria; Lao PDR, Afghanistan, Haiti, Timor-Leste – these are among the world’s poorest countries, many of which are also sites of conflict, war and other crisis situations, such as earthquakes and flooding.

In other words, many countries still have very high maternal mortality ratios, including two very large countries, which account for a large proportion of deaths. Moreover, there is a growing gap between countries where improvements have taken place and many of the poorest countries, where most women are still simply not benefiting. Furthermore, as the May 2012 edition of RHM shows, there are differences within countries and between women (according to socioeconomic status, rural vs urban status, age and marital status) that are sometimes great and must not be ignored. The paper by Shah and Ahman, for example, shows that unsafe abortion deaths remain high in many countries and that young women are at the greatest risk of death and complications from unsafe abortion. A study in Nigeria shows that women in northern Nigeria are at far greater risk of maternal death than women in the south of the country. Given that the primary aim of the Millennium Development Goals is to reduce poverty and the consequences of poverty, celebration is perhaps not yet in order. However, countries where improvements have clearly taken place, such as Rwanda and Cambodia, as shown in other RHM papers, certainly deserve credit for enormous efforts.

Limitations of global estimates of maternal mortality – Nepal

15/06/2012 Comments Off on Limitations of global estimates of maternal mortality – Nepal

The latest United Nations publication on global estimates of maternal mortality was released in May this year. Some of the news from this report is good, that despite big regional variations, overall maternal mortality is reducing at a global level.

One limitation of the estimates is that they fail to shine a light on the stark disparities between countries, some of which have made little if any progress, or within countries, for example between women living in rural and urban areas. They mask inequity in access for poorer women which characterises health service provision in many countries, and which remains a huge stumbling block to tackling the preventable causes of maternal death.

There is also concern that different estimates from a range of sources confuse the picture for those in the field; that the estimates cannot provide a comprehensive understanding of what works or how to explain reductions in maternal deaths – information which is essential if further progress is to be made;  and, most worryingly, that the perception of success in reducing maternal deaths may lead to complacency or neglect of the problem.

Nepal

In Nepal, maternal mortality has reduced from 770 to 170 deaths per 100,000 live births between 1990 and 2010, thus reaching the 75% reduction MDG target for 2015. The new estimates are only one of a series of different estimates released and published. The others were published in the Lancet and by WHO here, here and here.

These papers report different estimates of maternal mortality (calculated using different methods) relevant to approximately the same period of time. On the surface, the estimated reductions in Nepal should be reason for optimism, especially as all the estimates suggest a falling trend of maternal deaths in Nepal. But these new estimates have caused confusion and frustration in Nepal.

The confusion arises because the estimates do not agree, so it is not possible to say what the current level of maternal mortality is. Some people believe that the estimates report improbably low levels of maternal mortality and a larger than expected reduction over the last two decades, given the difficult geographical terrain, relatively low access to maternity services and variable standards of care in Nepal. Their frustration arises from the difficulty in interpreting these estimates to ensure that maternal and reproductive health services do not become neglected.

Maternal mortality is notoriously difficult to measure . For now, Nepal will have to deal with the uncertainty of the estimates, at least until the national demographic and health survey planned for 2016 provides more data for better estimates. Instead of debating what the actual level of mortality is or which estimate to use, what needs to be done is to draw on the situation to generate interest in finding out why the reduction is occurring. First steps have been made to do this , but more evidence needs to be gathered to build up a convincing picture of what changes are being experienced in Nepal. The reasons we find may not necessarily be what we might assume or expect, and will provide valuable lessons for other countries still striving to reduce maternal deaths.

A guest blog by Julia Hussein

Senior Clinical Research Fellow Immpact,
Scientific Director Ipact, University of Aberdeen, UK

Reproductive Health Matters

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Maternal health: hospital delivery does not guarantee good care

25/05/2012 Comments Off on Maternal health: hospital delivery does not guarantee good care

Hospital delivery does not guarantee good care: recent cases of women who died in a referral hospital in a sub-Saharan African country

Published on the British Medical Journal Guest Blog, 17 May 2012

A key focus of work in the field of safe motherhood has been on increasing deliveries in medical facilities with access to skilled birth assistants and emergency obstetric care. In many places more and more women are reaching clinics to deliver. However, there has been too little focus on the quality of services, on the capacity of health centres to provide care to all who need it, and training of staff to provide timely, skilled and compassionate care. Stories of women dying preventable deaths and enduring serious injury in health facilities demonstrate that accessing a hospital is not enough if the health professionals women depend on for their care are callous, negligent or corrupt.

We hope by sharing these true stories of women who were injured and died we are honouring the desire of the doctor who sent them to us to share them and to shine a light on what is happening in his region.

Case 1
A woman, aged 29,  is languishing in  hospital after losing both her baby and her uterus and rupturing her bladder while trying to give birth. She was rushed to hospital three months ago after she failed to deliver her six-pound baby. According to her best friend, on arrival at this referral hospital, she was not attended to as the medics on duty said the theatre was closed for the day and there was not much they could do. With the baby halfway out, she had to bear the pain till midday the following day when the by-then dead baby was removed. By that time her uterus had ruptured and also had to be removed, while her bladder muscles were so damaged that she can no longer control the flow of urine or stools. Although she was sent home after the ordeal, she had to return three weeks ago after her condition worsened. She needs urgent surgery, and a nurse on duty said she was on the list for a surgery camp currently in northern Uganda, which is expected this week. Meanwhile, she is experiencing a lot of pain in her abdomen, private parts and legs. She does not understand why she can’t be operated on in the hospital. According to her friend, doctors said that she would need to pay (equivalent to USD 1,223) for the operation. Often, such cases are transferred to other areas.

Case 2
The contractions had started at dawn. C, a school teacher, knew it was time, so she did what was expected – checked into a hospital at 6am so she could give birth with expert attention at her disposal. But that was not to be. For more than 10 hours after she checked in, she was ignored, neglected and writhing in pain in the Labour Ward until 8pm when she breathed her last. Her crime? She did not have the money (equivalent to USD 122) the medical staff demanded before they would attend to her. So she wasted away as her husband ran desperately around the village to raise the money. It was only the hospital cleaners who tried to help remove the baby from her womb. A neighbour, who had help transport her to the hospital, said she and C’s husband could not raise the money as they had spent the little money they had to purchase surgical equipment. “When I came back, I found her in pain, crying, there was no help. The medical workers looked on as they asked for money,” the neighbour added. After three hours of waiting and sensing that C was deteriorating, the neighbour approached a midwife and asked her to attend to her but the midwife and a doctor allegedly also declined. “At about 6pm, C started gasping; she fell on the floor and was bleeding. “That was when the doctor responded and took her into the theatre, but it was too late; her life could not be saved and she died.” The doctor emerged from the theatre after about 10 minutes and announced that both C and the baby had died. C had been going with her husband for antenatal check-ups at the hospital and the midwives had told them the baby was big, and that it would be difficult for her to have a normal birth, and they had apparently recommended a caesarean section. Causes of death were obstructed labour, uterine rupture and haemorrhage. A complaint was filed with the police and the doctor was being investigated for neglect. The police surgeon who carried out the autopsy said this was not the first case at this hospital; many women had died in labour due to neglect. The district Police Commander said he had summoned the medical staff on duty that night and day to furnish evidence. However, the hospital director said at the time of C’s death, there was another woman in the operating theatre and that it had been inadvisable to halt that operation. “And in any case,” he said, “it is not the patient who asks for theatre but we examine the patient and recommend. Doctors on duty examined her and by the time they recommended her for theatre she had already ruptured her uterus… She was bleeding and we could not save her life. I can’t rule out the issue of [staff] asking for money. Some staff do it but we need to investigate this further because it has no proof.” He said the people who operated on her to remove the baby were not hospital workers but imposters who had sneaked into the hospital.

Case 3
A woman 39 year old woman died after giving birth and failing to expel the placenta for several hours. She called for the help of the nurses on duty, according to eye witnesses, but got no attention. In an interview with the local newspaper, the doctor on duty said that after the call, he had rushed to the hospital to save the situation but it was already late to save her life. He denied the claim that the woman died out of negligence because an unqualified hospital staff member had helped her instead. The District Chairman said serious action must be taken against the implicated health workers to serve as a warning, as negligence in hospitals is forcing women to visit traditional birth attendants.

Case 4
Another tragedy has occurred in A. An expectant mother of five, aged 37, died in the regional referral hospital having just been admitted at 9 pm and died due to unprofessional conduct by the health workers. Not even the simplest effort was made to help the poor women. The doctor was raised on the phone to come and attend to her, but she kept saying that she was too tired to come that night and that she would attend her the next day. The next morning, however, no one attended to her till she met her death. When she asked for help, the midwives were shouting at her, and the poor women fell off the bed due to severe labour pain. The nurses panicked and pretended to work on her to save her life but she died together with her baby still in the womb. As one enters the maternity ward at this hospital, there is a smell of death and fear among the expectant mothers. Her death has left many of them wondering if they will survive delivering in the hospital.

*****************

Though these stories are sent from sub-Saharan Africa, they are a perfect echo of the case studies from India(1) in RHM’s May Issue on Maternal Mortality in which discrimination and neglect led to preventable deaths . In India human rights law has been used for the first time to bring compensation to the family of a woman who died a preventable death and to enshrine the principle that a woman has the right to lifesaving treatment during and after childbirth (2) . In Uganda, human rights organisations and families of women who died in childbirth are filing a landmark lawsuit to hold the government accountable for maternal deaths (3); while in Latin America landmark decisions by the Committee on the Elimination of Discrimination Against Women (CEDAW) have called for appropriate maternal health care, in Brazil, and decriminalisation of abortion to safeguard women’s health in Peru (4).

To read more about how people are using the law and human rights conventions to commit governments to improving maternal health care see May’s issue of Reproductive Health Matters Maternal Mortality or Women’s Health: time for action
(1)Subha Sri B, et al. An investigation of maternal deaths following public protests in a tribal district of Madhya Pradesh, central India. Reproductive Health Matters 2012; 20(39). In press.

(2)Kaur J. The role of litigation in ensuring women’s reproductive rights: an analysis of the Shanti Devi judgement in India. Reproductive Health Matters 2012; 20(39). In press.

(3)Ugandan Government to be held accountable for maternal deaths

(4) Kismödi E, et al. Human rights accountability for maternal death and failure to provide safe, legal abortion: the significance of two ground-breaking CEDAW decisions. Reproductive Health Matters 2012; 20(39). In press.

A guest blog by Lisa Hallgarten: Social Media Manager at Reproductive Health Matters; sexual health trainer, educator, and blogger at Education For Choice; and advocate for better sex education for all young people.

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