China: how can the one-child policy and rights-based family planning be reconciled in the face of recently reported abuses?

23/07/2012 Comments Off on China: how can the one-child policy and rights-based family planning be reconciled in the face of recently reported abuses?

Lisa Hallgarten, RHM social media and communications

Marge Berer, RHM editor

Two recent news stories from China have reawakened concern about overzealous enforcement of China’s one-child policy and the emergence of voices critical of the policy and its implementation. Historically, being a country with 25% of the total world population within its borders, China’s population policy has addressed a unique set of social, demographic and political circumstances, and overall, it appears to have had widespread support from the public. However, these two reports have resonated internally and far beyond its shores.

In the United States, the story of Chen Guangcheng ,the Chinese civil rights activist imprisoned and persecuted for exposing and protesting against abuses of women being forced to have abortions against their will, in the name of Chinese government policies, has been co-opted by anti-abortion US activists. Though he has spoken out mainly against the brutality of forced abortions, not abortion per se, he is being used as a poster boy by the US anti-abortion, anti-contraception movement. Stories of forced abortion, and other human rights abuses associated with the one-child policy, are being presented as the logical conclusion of all and any family planning policies.

In one of two recent stories that hit the press due to US publicity, a mother of one was snatched from her home and forced to have an abortion. The procedure went tragically wrong and just hours later the 38-year-old woman was dead.  In another report, a woman who was seven months pregnant was also forced to have an abortion.  The story and pictures of the woman lying beside the aborted fetus were posted on the internet, generating over a million hits on Chinese social media networks. In response, the officials in the second of these cases lost their jobs and were prosecuted  More recently the women was given financial compensation as well.

At the same time, a flurry of anecdotes from other parts of China have started to emerge about the practice of forced abortions: contradicting the official party line that such practices – especially abortions in late pregnancy – are illegal, rare and not countenanced by the government.

A look at the Population and Family Planning Law of China  is instructive. It aims to maximise contraceptive use and minimise population growth by providing local and district officials with financial and other rewards for meeting family planning targets. The motivation this might create for officials to be overzealous in their implementation of the policy is tempered with tepid instructions not to infringe the rights of women and families and to promote family planning using incentives rather than coercion. In one of the cases above, the woman and her husband were threatened with a huge fee if they wished to continue the pregnancy, which they could not have afforded. This raises questions of which incentives and disincentives, if any, are acceptable to the population, how to prevent coercion, what to do when it happens, and what rights women have to redress and compensation when coercion has been shown to take place. Underlying these questions are broader policy issues – whether it is possible to reconcile the need to limit population growth with its attendant targets for coverage of contraception and even abortion.

The Family Planning Summit in London this month said that the funding associated with the new FP Initiative will explicitly NOT be used to support coercive family planning. It did, however, set ambitious targets for contraceptive coverage, though when criticism was raised, the language was changed to read contraceptive access. Whether it will be possible to achieve a huge increase in contraceptive use without incentives and targets, and how this relates to donor expectations with “results-based financing”, remain on the table for discussion. The consequences for informed choice and the right to use or not to use a method hang in the balance. At the same time, given the many barriers to accessing as well as using contraception successfully in the world’s most underserved communities, there will be enormous pressure to prove that the initiative really can give 120 million more women access to contraception.

The anti-abortion, anti-contraception movement would love to discredit the whole programme, as they have sought to do for years in the United States as regards the Chinese policy. Everyone who supports the right to control fertility needs to be committed to ensuring that any new programmes providing contraception will have women’s rights at their heart in practice. If they don’t, this one-off commitment of money may never be repeated.

Also in the news on this issue:
A group of Chinese scholars have written an open letter calling for revision of the one-child policy. They argue that the policy is bad for human rights and also for sustainable economic development.  Some Chinese demographers have said the one-child policy will damage the country as low fertility rates threaten a shortfall in the productive labour force needed to fund the ageing population.

We have no idea whether these statements are typical of public views. The public debate that has ensued inside China since these reports have come out must be multi-faceted and far from one-sided. We would be happy to receive further reports of the many points of viewbeing expressed in this debate, including by the government, as it unfolds within China.

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

Botched motherhood

11/07/2012 Comments Off on Botched motherhood

A poem by Tiro Sebina – featured in Reproductive Health Matters May 2012
You may not want to hear
About a woman who died
In labour in a hut

You may not want to hear
About an expectant woman
Who perished aboard
A donkey cart
On a bumpy road to an apology
Of a health post
With neither doctors on site
Nor drugs in sight

You may not want to hear
About an expectant woman’s fatal fall
Off a rickety bike
Pedalled by a drunken man
Terrified of Emang Basadi
Concerned about his name
Appearing on the birth certificate

You may not want to hear
About a woman who expired
Without knowing
She was targeted by grand visions
And millennium schemes

You may not want to know
About a woman too hapless
To grace dinner-conferences
Held in her name
At exclusive venues

Who wants to know
About the bungled chaos
Of a dead mother

All I had to do was take a pill every day, I was told, and hey presto, I didn’t have to worry about getting pregnant!

11/07/2012 Comments Off on All I had to do was take a pill every day, I was told, and hey presto, I didn’t have to worry about getting pregnant!

Marge Berer, Editor, Reproductive Health Matters

I was among the first generation of women in the 1960s to experience the miracle of the pill just at the age when I was wanting to start having sex. All I had to do was take a pill every day, I was told, and hey presto, I didn’t have to worry about getting pregnant if I didn’t want to, and it worked! But oh, if only it had all turned out to be that easy! Like one in three women in the UK today, a country where contraceptive prevalence is almost as high as it can get, I needed an abortion several years later. Again, I was lucky, the 1967 Abortion Act meant I was able to get a legal abortion. The lesson is simple – while contraception continues to be a miracle, because it helps people not to have children if and when they don’t want to, it is not enough on its own and it never has been.

Family planning has been out of the news for a long time, and suddenly it’s back. Welcome!! Bring out the red carpet, and I mean it!! Women and men need contraception now as much as they have ever done, and young women and men who are beginning to explore their sexuality together need contraception and condoms more than anyone. But there has been a lot of water under the bridge since family planning was promoted as the cure-all for the world’s ills in the 1960s when the pill came out, and everyone needs to study that history anew so that the same mistakes, of which there have been many, and the same narrow vision, are not repeated.

My generation of women’s health activists, along with a whole generation of researchers, service providers and policymakers who brought their knowledge together at the International Conference on Population and Development in 1994, got the world to recognise that the need for the means to control fertility, which is as old as history itself, was part of a much broader set of needs related to reproduction and sexuality, and that these were inextricably connected. These include: being able to have sex without fear of negative outcomes, being able to have sex if and only if we want to and only with whom we want to, being able to have the children we want, being able to get pregnant at all, being able not only to survive pregnancy but also still be in good health, being able to have a safe abortion without fear of death or condemnation when an unwanted pregnancy occurs, being able to protect ourselves from sexually transmitted diseases, and being able to get treatment for all the many causes of reproductive and sexual ill-health, which start with menstruation and menstrual problems, and continue into old age with things like breast and prostate cancer and uterine prolapse.

There is indeed a huge unmet need in today’s world, but the unmet need for contraception is only a fraction of the unmet need for sexual and reproductive health, and for sexual and reproductive rights. The results we should be working for encompass every aspect of the issues I have just named, and those in turn must be seen in the even wider context of the right to health, social justice and an end to poverty and violence – which were the real point of the Millennium Development Goals – not the measurable targets.

I will be blogging about these issues in the light of the FP Summit over the next weeks – watch this space!

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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