19/07/2012 Comments Off on Family planning and safe, legal abortion go hand in hand
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.
16/07/2012 Comments Off on The morning after: the beginnings of an assessment of the FP Summit
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.
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
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
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.
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.
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.
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.
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.
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.
(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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05/03/2012 Comments Off on Is eradication of congenital syphilis feasible?
On 1 March, the Global Congenital Syphilis Partnership held a press conference to announce the launch of a global campaign to eradicate congenital syphilis, motivated by evidence from a seven-country pilot study that used a rapid blood test for screening. The aim of the studies was to test pregnant women for syphilis, treat any who were positive early in their pregnancies to avoid transmission of syphilis to their babies during pregnancy, and where possible also test and treat their husbands/partners.
If pregnant women are screened and treated as required in an antenatal visit early in pregnancy, congenital syphilis will be treated in the woman and prevented in the infant, but this is only as long as the woman is not re-infected during the rest of her pregnancy. To avoid that, her partner needs to be tested with her and both need to have an injection of penicillin if positive for syphilis. If the woman has more than one partner, then contact tracing and screening will also be needed.
Screening of pregnant women for syphilis is a long-time public health measure, and has been recommended as a routine antenatal test by WHO and other national, regional and global public health bodies for many decades now. However, periodic studies in the latter half of the 20th century showed that many women are not screened during antenatal care, others have not returned for their results, and still others are not screened because they have not attended for antenatal care at all, or only very late. Hence, efforts to eliminate congenital syphilis have failed. Although in most countries the rates appear to have been falling over the years, the burden of disease remains heavy.
Untreated syphilis in pregnancy leads to adverse pregnancy outcomes in more than half the women with active disease, including early fetal loss, stillbirth, prematurity, low birthweight, neonatal and infant death and congenital disease among newborn babies. Similarly to HIV, syphilis in pregnancy is both sexually transmitted and transmitted through blood in shared needles by injecting drug users. Testing for both syphilis and HIV at the same time makes good sense in antenatal care settings, since the blood taken to screen for syphilis can also be tested for HIV, though treatment modalities are of course quite different.
In 2008, the latest year for which global data are available, approximately 1.9 million pregnant women were infected with active syphilis resulting in approximately 300,000 stillbirth sor early fetal losses, 140,000 neonatal deaths, and 380,000 infants that were preterm, of low birthweight, or had congenital disease associated with syphilis.
Several new factors mean that it is becoming more feasible to lower these rates. First, the development of a rapid blood test for syphilis means health workers can get a result in only a few minutes without the need for laboratory facilities, as the kit includes a built-in testing mechanism. If the test is positive for syphilis, an injection of penicillin can be given immediately. This is sufficient as treatment, and as long as there is adequate availability of penicillin, and unless re-infection is a risk, does not require follow-up.
The other important facilitating factor is that more and more women in the developing world are attending for antenatal care, and more often making more than one visit. Ensuring that all of them are tested is a major task, however. According to a 2011 WHO report:
“In 2010, 63 low- and middle-income countries reported on the proportion of women attending antenatal care tested for syphilis at the first visit. In this subgroup, 17 low- and middle-income countries reported having achieved the global target of testing at least 90% of women attending antenatal care at the first visit for syphilis (Belize, Chile, Cuba, Fiji, Gabon, Grenada, Guyana, Kiribati, Malaysia, Mauritius, Namibia, Oman, Samoa, Seychelles, Sri Lanka, Uruguay and Venezuela (Bolivarian Republic of)). Overall global median testing coverage did not improve from 2008 to 2010 (Table 7.2). Nevertheless, median testing coverage improved in Latin America and the Caribbean (from 73% in 2008 to 80% in 2010) and in East, South and South-East Asia (from 52% to 78%). In 27 reporting countries from sub-Saharan Africa, a median of only 59% of pregnant women were tested for syphilis. Eight low- and middle-income countries reported not offering routine syphilis screening in antenatal care in 2010.”
Hence, there are big “ifs”. Shortages of essential medicines are well known. And re-infection is often a risk because husbands and other sex partners historically were often not tested and treated at the same time as the woman, or at all. To get most partners into antenatal clinics for testing will be one of the more difficult challenges for antenatal programmes, and may not be seen as a priority, given all the other demands on antenatal care these days which are not being met, such as the need for more trained midwives. Other cadres of health workers can be trained to do the test and give injections, but this too would take resources and people and time.
I am concerned that the new Global Congenital Syphilis Partnership is about congenital syphilis and therefore neonates only, and that the UNAIDS-led Global Plan toward the Elimination of New Infections among Children by 2015 and Keeping Their Mothers Alive, launched last year, which includes a global initiative to eliminate congenital syphilis, is about women and children only. But shouldn’t women and men be the focus of treatment in order to prevent syphilis in neonates? Luckily, unlike with PMTCT, efforts to reduce congenital syphilis must treat the pregnant woman to protect the fetus but will programmes also bring in the men?
My other concern is the use of the words “eradicate” and “eliminate” in the descriptions of the goals of this and other initiatives, such as the prevention of mother-to-child transmission of HIV, also in the UNAIDS Global Plan, and the so-called “Golden Moment” in relation to unmet need for family planning. The Americas and the Asia-Pacific region and several countries have developed integrated initiatives to eliminate mother-to-child transmission of both HIV and syphilis, given their common target groups and service delivery platforms.1
Can these new global health initiatives make such massive advances in reducing major disease burdens in a few short years that they will be able to eradicate or eliminate them? Do they think such claims are necessary to gain credibility? Smallpox is the only disease that has ever been eradicated to date. Should we not continue to occupy the more cautious terrain of public health agencies and experts in terms of expectations? Perhaps this is an old-fashioned view.
The figures for declines in neonatal deaths are encouraging, even if they are happening less quickly than other infant and child mortality declines. In 2009, an estimated 3.3 million babies globally died in the first month of life, compared with 4.6 million in 1990. This is in spite of world population growth. More than half of all neonatal deaths occurred in five countries of the world (which also account for 44% of global live births): India 27.8% (19.6% of global live births), Nigeria 7.2% (4.5%), Pakistan 6.9% (4.0%), China 6.4% (13.4%), and Democratic Republic of the Congo 4.6% (2.1%). Between 1990 and 2009, the global neonatal mortality rate declined by 28% from 33.2 deaths per 1,000 live births to 23.9. The proportion of child deaths that are in the neonatal period increased in all regions of the world, and globally is now 41%. Thus, neonatal mortality rates were halved in some regions of the world, though Africa’s rate only dropped 17.6% (43.6 to 35.9). These reductions are impressive and give much hope of future successes.
At the press conference, Peter Piot, formerly head of UNAIDS and now head of the London School of Hygiene & Tropical Medicine (LSTHM), in his introduction, described treatment of congenital syphilis as a low-hanging fruit, and Joe Cerrell, representative of the Bill & Melinda Gates Foundation for Europe, said, referring to the new test kits: “We have a simple solution to save a million children’s lives each year.”
Rosanna Peeling from LSHTM handed out a Rapid Syphilis Toolkit produced by the School and reported that 30 countries have already started scaling up rapid antenatal syphilis/HIV tests. She talked about wanting to avoid “more vertical programming” with this new programme. However, her definition of an “integrated programme” in this instance was the two-for-one combination of syphilis and HIV testing of pregnant women at one go. Given the limitations of antenatal care and the real meaning of integration, this is hardly it. The seven country studies have not yet been published, however, and details of what this does mean in practice were not provided.
In the pilot programme in Brazil, presented by Adele Benzaken, in the Amazon region they have shown that it is possible to do these tests in a very rural, hard-to-reach region. Yet they will have to test and treat two million pregnant women and their partners each year. Brazil has got a Brazilian pharmaceutical company to produce the test kits, thus controlling cost, and are funding 95% of the programme themselves (Simone Diniz, personal communication). Given their success with HIV, again optimism is warranted.
In China, the head of the National STD Control Programme said that it was precisely in the rural areas of the country that they have a major outreach problem that must be solved. China thought they had eradicated syphilis, but it returned in the 1980s. With the mass internal migration that has taken place in China in recent decades, eradication may be more difficult, especially since migrant women do not have access to health insurance and get far poorer maternity care.
“Eradication” or “elimination” of congenital syphilis, rather than “control” has a very different meaning and implications. To achieve eradication of syphilis in women and children, according a paper by specialists from the Centers for Disease Control and Prevention (USA), published in RHM in 1995, you need:
- a control measure that is completely effective in breaking up transmission
- effective case detection and surveillance
- recognition of the disease as of socioeconomic importance in the countries concerned
- reasons to attempt eradication as opposed to control
- adequate financial, administrative, person power and health service resources, and
- the necessary socio-ecological conditions.
Most low-resource countries couldn’t possibly meet these conditions. Still, syphilis in pregnant women could be reduced far more if antenatal care programmes were doing what all the guidelines and protocols have been telling them for years that they’re supposed to be doing – a range of antenatal screening tests that include not only syphilis and HIV, but also screening and treatment for anaemia, malaria and TB, and all the other checks that contribute to healthy pregnancies and babies.
What was not raised at all in the press conference were other STIs, in addition to syphilis and HIV. More than 448 million new cases of four bacterial STIs – gonorrhoea, chlamydia, and trichomoniasis as well as syphilis – are estimated to have occurred in 2005 alone. These also contribute to major morbidity and even mortality. The point was made in this press conference that when HIV testing was made the screening priority in pregnancy by the global AIDS community, a lot of routine syphilis testing stopped. We should take good note, since this is a prime example of why so many of us working in health believe that vertical programming is a big mistake.
 The test used in the pilot studies, carried out by the London School of Hygiene & Tropical Medicine, cost US $1 per kit. However, in Brazil, where one of the studies took place, a national pharmaceutical company is producing their own test kits for use in scaling up the programme, whose price is likely to be far lower (Simone Diniz, personal communication 24 February 2012).
 Oestergaard MZ, Inoue M, Yoshida S, et al. Neonatal Mortality Levels for 193 Countries in 2009 with Trends since 1990: A Systematic Analysis of Progress, Projections, and Priorities. PLoS Medicine 2011. http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.1001080.Mikkel Oestergaard and colleagues develop annual estimates for neonatal mortality rates and neonatal deaths for 193 countries for 1990 to 2009, and forecasts into the future.
 For a discussion of this sort of assessment of complex health issues in: Richard F, Hercot D, Ouédraogo C, et al. Sub-Saharan Africa and the health MDGs: the need to move beyond the “quick impact” model. Reproductive Health Matters 2011;19(38):42–55.
 RHM has a paper in press for May 2012 that illustrates this in relation to declines in maternal mortality in Shanghai.
 Kennedy MG, Spink Neumann M, Fichtner RR, et al. Can we eradicate syphilis in pregnant women and newborns? Should we try? Reproductive Health Matters 1995;3(6):94–103.
 World Health Organization.Prevalence and incidence of selected sexually transmitted infections: Chlamydia, Neisseria gonorrhoeae, syphilis and Trichomonas vaginalis. Geneva: WHO, 2011.
Hormonal contraception and risk of HIV: new studies, the issues, and the response of the World Health Organization
20/02/2012 Comments Off on Hormonal contraception and risk of HIV: new studies, the issues, and the response of the World Health Organization
Many feminists, including me, actively opposed the hormonal injectable contraceptive Depo Provera (DMPA) three decades ago ̶ it was at a time when certain women weren’t being given a choice of method or any information about possible side effects, and before long-term post-marketing studies began to be done to monitor long-term safety. Here in the UK, we demanded that all women be given information about side effects and a choice of methods, and we called for long-term safety studies. The research was duly done, and it found that the side effects were within the range of what experts consider to be safe and acceptable. Once these were known and women began to be given a choice of method, there was nothing more to oppose.
Injectable contraception has distinct advantages ̶ it is highly effective, the woman and her partner need do nothing more in between injections to gain protection from unwanted pregnancy, and women can use it without partner consent or knowledge if they need to. However, like all hormonal methods, female sterilisation and IUDs, injectables do not provide protection against sexually transmitted infections, including HIV. For that, people need to use condoms or other forms of safe sex, or always have sex with only one partner (who is negative) who also always has sex only with them (also negative).
Many studies have been done on whether hormonal contraceptives increase HIV risk or not, and the findings have sometimes shown an increased risk and sometimes not. This variation is because there are a lot of confounding factors and risks involved that are extremely difficult to control for. On PubMed, for example, a study on this subject at the very top of the page using the keywords “Depo Provera and HIV risk” today reached the following conclusion: “In this study conducted among [5,567] South African women, hormonal contraception did not significantly increase the risk of HIV acquisition. However, the effect estimate does not rule out a moderate increase in HIV risk associated with DMPA use found in some other recent studies.”[i]
Several other recent studies, however, have found an increased risk of HIV acquisition among Depo Provera users. As a result the Department of Reproductive Health and Research/Human Reproduction Programme at the World Health Organization held an expert consultation several weeks ago to consider the latest evidence and decide whether it warranted a change in their current guidance, dating from 2009, on this subject. They decided not to change their current advice. Below is the press release they sent out a few days ago, explaining this. The fact remains, it’s the lack of safe sex/condom use and sex with more than one partner, or with a partner who has more than one partner, that really puts women and men at risk of HIV. That hasn’t changed since the HIV epidemic began.
WHO Press Release (a different version of this release is available on the WHO site):
WHO upholds guidance on hormonal contraceptive use and HIV
Geneva, 16 February 2012. Following new findings from recently published epidemiological studies, HRP convened a technical consultation (from 31 January to 1 February 2012) regarding hormonal contraception and HIV acquisition, progression and transmission. It was recognized that this issue was likely to be of particular concern in countries where women have a high lifetime risk of acquiring HIV, where hormonal contraceptives (especially progestogen-only injectable methods) constitute a large proportion of all modern methods used and where maternal mortality rates remain high. The meeting was held in Geneva between 31 January and 1 February 2012, and involved 75 individuals representing a wide range of stakeholders. Specifically, the group considered whether the guideline Medical eligibility criteria for contraceptive use, Fourth edition 2009 (MEC) should be changed in light of the accumulating evidence.
After detailed, prolonged deliberation, informed by systematic reviews of the available evidence and presentations on biological and animal data, GRADE profile summaries on the strength of the epidemiological evidence, and analysis of risks and benefits to country programmes, the group concluded that the World Health Organization should continue to recommend that there are no restrictions (MEC Category 1) on the use of any hormonal contraceptive method for women living with HIV or at high risk of HIV. However, the group recommended that a new clarification (under category 1) be added to the MEC for women using progestogen-only injectable contraception at high risk of HIV as follows:
Some studies suggest that women using progestogen-only injectable contraception may be at increased risk of HIV acquisition, other studies do not demonstrate this association. A WHO expert group reviewed all the available evidence and agreed that the data were not sufficiently conclusive to change current guidance. However, because of the inconclusive nature of the body of evidence on possible increased risk of HIV acquisition, women using progestogen-only injectable contraception should be strongly advised to also always use condoms, male and female, and other preventive measures. Expansion of contraceptive method mix and further research on the relationship between hormonal contraception and HIV infection is essential. These recommendations will be continually reviewed in the light of new evidence.
The group further wished to draw the attention of policy-makers and programme managers to the potential seriousness of the issue and the complex balance of risks and benefits. The group noted the importance of hormonal contraceptives and of HIV prevention for public health and emphasized the need for individuals living with or at risk of HIV to also always use condoms, male and female, as hormonal contraceptives are not protective against HIV transmission or acquisition.[ii]
[i] Morrison CS et al. Hormonal contraception and the risk of HIV acquisition among women in South Africa. AIDS 2012;26(4):497-504.
[ii] Technical statement: Hormonal contraception and HIV and background documentation.
16/12/2011 Comments Off on Jingle pills indeed
This post first appeared on the BMJ Group Blog, 12th December 2011
Many years ago now, when news of female sterilisation first came out, Catholic priests in Puerto Rico and other Catholic countries preached from their pulpits against women being sterilised. As a result many more women learned that sterilisation existed, and many went out from church asking where to get it. In effect, the church gave family planning free advertising space by opposing it. Recently, the Daily Mailand others who rant against emergency contraception and abortion have played a similar role.
The British pregnancy advisory service (Bpas) received widespread coverage for their Christmas morning-after pill campaign, in which they offer to send women who request it free emergency contraception if they phone in and discuss it with a nurse.
This campaign represents several major advances in support of women who may be having sex without using a regular contraceptive method, but do not want to get pregnant. First, Bpas are making the service available by phone in advance of the “emergency” nature of the need. Thus, just as we keep pain medication in the medicine cabinet in case we get a headache, women are being encouraged to have morning-after pills on hand, in case they need them. Second, they are making the pills free when many chemists charge £25 for one dose, which many young and unemployed women would find prohibitive, and the phoneline will be open when GPs and chemists are closed. Third, they are able to broach regular contraceptive use with the women who phone and encourage them to start regular method use.
The morning-after pill has been available over the counter from chemists without a prescription for over-16s since 2001. So all the palaver about Bpas suddenly making it as easy as dialling for a pizza is silly. In any case, if you’ve had unprotected sex, the morning-after pill will help you far more than pizza. There are people who simply don’t want any form of birth control to be easily accessible and who still claim that emergency contraception (and abortion) promote promiscuity, just as their anti-abortion forbears claimed about the contraceptive pill and female sterilisation in their day. In the end, it’s sex they’re against. Perhaps Nadine Dorries should try putting that on prescription!
A Cochrane review in 2010 found that women who received an advance supply of the morning-after pill had the same chance of becoming pregnant as those who did not have early access to the method. However, these pills do prevent pregnancy when they are used. It seems that many of the women who have unprotected sex and get pregnant without wanting to are not the ones actually obtaining and using the morning-after pill. Perhaps Bpas’ campaign, with the help of all the media who have given it space, will help to change that.
According to the Bpas press office, 1,000 women phoned in the first 48 hours. If many more women find out about this method and start to keep a dose or two at home in case they need it, there is a far better chance they can avoid an unwanted pregnancy.
Andrew Lansley, the Health Secretary who doesn’t want responsibility for the NHS, told the Daily Telegraph that he would prefer there to be face-to-face counselling. Is that actually necessary when only a few questions need answering? And, someone has to seek face-to-face counselling first. For those who don’t, or won’t, this can only be a good thing.
Indeed, helplines for health-related issues are becoming more common and their value is clear. The FPA, for example, has run a helpline for years and has an excellent record of informing and referring for services for family planning and sexual health. The new aspect of Bpas’ campaign, sending the pills through the post, is like ordering something on the internet. Why not?
As for the under-16s, let’s get real. The under-16s who have sex may only do so very irregularly. But if they’re going to have sex, they need access to contraception. The morning-after pill may not be their best option in the long run, but it should be there if they need it.
We need contraception to be in the news more often – it’s good news. I applaud Bpas and all the media who have publicised their campaign. Jingle pills indeed! Happy holidays!