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

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

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

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

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

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

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

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

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

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

 

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!

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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Is eradication of congenital syphilis feasible?

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.[1] 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.[2]

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.[3] 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).[4] 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,[5] 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.[6]

“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.[7]

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.[8] 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.


[3] 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).

[4] 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.

[5] 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.

[6] RHM has a paper in press for May 2012 that illustrates this in relation to declines in maternal mortality in Shanghai.

[7] 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.

[8] World Health Organization.Prevalence and incidence of selected sexually transmitted infections: Chlamydia, Neisseria gonorrhoeae, syphilis and Trichomonas vaginalis. Geneva: WHO, 2011.

In defence of abortion on a woman’s request, including on grounds of fetal sex

24/02/2012 Comments Off on In defence of abortion on a woman’s request, including on grounds of fetal sex

Published on the British Medical Journal Guest Blog, 24th February 2012

Ach, what a furore. The Daily Telegraph is in its element and having a ball printing nasty allegations about doctors doing abortions illegally on grounds of sex selection. Let’s look at the issues a bit more dispassionately. First, is it actually illegal? Yes and no. The 1967 Abortion Act does not permit abortion on grounds of sex selection per se, it is true, and the law is framed so that anything that cannot be defended as coming under one or more of the named legal grounds is technically illegal. However, the question remains whether abortion on grounds of sex selection can be defended under the existing legal ground for abortions. I believe the answer is yes.

Sex selective abortion, like late second trimester abortion, lends itself to easy condemnation and stigma, and many otherwise pro-choice people are opposed to it. In India and China, where the laws on abortion are otherwise very liberal, sex selective abortion is subject to several laws banning it, all of which are totally ignored  ̶ both because women are under great pressure to have boys, especially women whose first child was a girl and who have only one or two chances, and because those doing the ultrasound scans are making a lot of money from them.

This isn’t a question of designer babies, though it is always the case that where something is possible technically, and is available for a range of reasons, e.g. determining whether there is a risk of sex-specific genetic anomalies, it will also be used in other ways. In this sense, finding out fetal sex during an ultrasound scan is inevitable and justified. This information belongs to the parents and should not be withheld. The baby is theirs after all. Preferring a baby of one sex over the other is nothing new, but has become more of an issue, according to the literature on sex selection in Asia, precisely because people are having so few children. But this is not just a cultural or ethnic issue. I watched my next-door neighbour treat her second child, a boy, badly throughout his childhood because she had wanted a second girl. She never forgave him for being born, at a time when there was no ultrasound for finding out fetal sex. Is this so uncommon?

I believe doctors faced with a request for abortion from women whose cultures practise discrimination against women and girls can justify it under the existing abortion law on the following grounds: taking the woman’s social situation into account, and because the woman’s physical and mental health and well-being may be at risk, and also her existing children. The potential for abuse of a woman by her husband and family, and poor treatment of and even purposeful neglect of girl children (leading to poor development and even death), are common outcomes in Asian cultures that demand that women produce boys. Women can be rejected and their lives made miserable. No one that I am aware of has ever investigated the existence or extent of such abuse and neglect in the UK among families from these cultures, but perhaps it’s time someone did. Moreover, it is also the case that a woman may not want another baby anyway, for other valid reasons, and fetal sex may be the only acceptable excuse she can give in her family situation for seeking an abortion.

Lastly, if anyone thinks that incrimination, condemnation and prosecution of pro-choice doctors is going to make this situation go away, they need to think again. Women will simply say they have a different reason and doctors will duly record it.

I believe health professionals and everyone who is pro-choice on abortion should support pro-choice doctors and women seeking abortions, whatever their reasons, even when sex selection may be involved.

The Daily Telegraph’s stories and the cowards who remain unidentified who went under false pretences to abortion providers and doctors who authorise abortions with the intention of incriminating them, should be condemned. Their aim is not to stop sex selection, which will not go away until discrimination against women and girls becomes history. Their aim is to stigmatise abortion and women who have abortions, to frighten women and abortion providers that they are breaking the law, and to seek to restrict the law on abortion. Their behaviour is unethical and under-handed, and constitutes harassment, which should be rejected and even subject to prosecution for wasting the Health Department’s and police time.

The UK needs to make abortion available legally on the request of the woman, and to decriminalise abortion altogether. This is an idea whose time would have come long ago if misogyny and harassment of women were illegal ̶ and prosecuted ̶ instead.

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.

http://www.who.int/reproductivehealth/topics/family_planning/hc_hiv/en/index.html

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