Collecting honest data on maternal deaths gives us the information we need to save women lives

Maternal death is one of the thorny problems of global health. Many different factors can cause a mother to lose her life – cultural attitudes about childbirth, geographical isolation, access to healthcare and the skill level of her healthcare providers. It’s difficult to save the lives of mother when you cannot identify what needs fixing.

In response to that challenge, the WHO developed a specific methodology known as Maternal Death Surveillance and Response (MDSR). Every country is now encouraged to have an MDSR system, which will “…generate data by ensuring that all deaths of women of reproductive age are notified, and that all probable maternal deaths are reviewed by experts. They promote methods that investigate all factors contributing to a mother’s death, such as verbal and social autopsy. And, crucially, they firmly couple surveillance and review to response – the process of generating evidence-based recommendations and using them to prevent similar maternal deaths.”

On Friday, WHO released the first global MDSR report. The report is not a collection of data on maternal death; it is too soon for that. Instead, it is an analysis of the current state of maternal mortality data and investigation. It outlines justification for using MDSR, paired with maternal death case descriptions that identify the kind of maternal deaths that better data can help prevent and a series of case studies of countries using MDSR. Overall, the report finds that most countries are committed to MDSR in theory but actual implementation of the system as intended to reduce maternal deaths varies greatly among countries.

According to the report, MDSR systems are essential because many maternal deaths, “…go completely unrecorded in countries that have weak systems for notifying vital events, or are misclassified under causes unrelated to motherhood. Maternal death reviews all too often focus solely on medical causes to the exclusion of other factors that may have contributed to a woman’s death, such as lack of transport or money to pay for care.” In addition, “Official reports underestimate the true magnitude by up to 30% worldwide and by 70% in some countries. This matters, because it is only by gathering and analyzing large volumes of quality data that we can identify trends in maternal mortality – including the causes of deaths and where they occur – and use the knowledge to target health programs and interventions that save women’s lives.”

The report describes the basics of an MDSR system: identification, investigation, and notification. To fulfill the requirement for identification and investigation, all deaths among women of reproductive age (15–49 years) in both health facilities and the community must be investigated to determine whether death occurred during pregnancy or the postpartum period. To fulfill the notification function, every suspected maternal death that occurs in a health facility must be notified to the MDR committee within 24 hours, and within 48 hours when a woman dies in the community.

Investigating maternal deaths contributes to both better data collection and vital statistics and the health system as a whole. Identifying health system gaps – such as poor emergency transportation – that lead to maternal death and resolving them increases quality of care for all patients.

Current Global State of MDSR

64 countries participated in the survey on maternal health data recording, and the WHO provided information on an additional 39 countries from its health system database. 86% of the countries had a requirement in place to notify all maternal deaths. 85% required that all maternal deaths be reviewed. However, only 46% of countries had maternal death review committees that met at least twice a year.

Obstacles to Collecting Better Data

The report summarizes six major obstacles to MDSR: 1) Awareness – health care providers, especially frontline workers, may not understand the importance of this kind of data collection 2) Blame culture – people involved in the process may withhold important information if they fear reprisals or disciplinary action following an MDR. 3). Staff and training  – Many countries report having insufficient numbers at all levels to cover all the work needed to prepare for maternal death reviews. 4) Data collection – personnel may be unclear on the actual mechanics and timeline of data collection. 5) Follow-up and sustainability – the maternal death findings have to be acted on; the data collection and investigation must not be an end in themselves. 6) Financial resources – many countries simply don’t have the money to effectively collect this data, or act upon it.

What the Report Doesn’t Say

Access to safe abortion care is a key component of maternal health, yet it is mentioned in the briefest possible terms in this major report on maternal death. Even in the section on obstacles to improving maternal care and cultural barriers, there is no mention of abortion.

One sentence takeaway

 

Collecting honest data on maternal deaths gives us the information we need to save women’s lives.

http://www.undispatch.com/collecting-honest-data-maternal-deaths-gives-us-information-need-save-womens-lives/

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Bangladesh – Reduced maternal mortality at the cost of what?

MAHMUDA Khan- General Secretary, Shishu Aangina, WHTF memberbangla.jpg

The maternal mortality in Bangladesh fell from 322 deaths per 100,000 live births in 1998-2001 to 194 deaths per 100,000liuve births in 2007-2010, indicating a huge success in the health sector. Moreover, Bangladesh has set targets to achieve the goal of the health, Population and Nutrition Sector development Program (HPNSDP) to reduce MMR to less than 143 deaths per 100,000 live births by 2016.

Though it is undoubtedly a huge success, but how this has happened where only 42% births attended by a skilled medically trained provider and 37% of births were delivered in health facility (BDHS 2014). Percentage of women received antenatal care and post-natal care has increased remarkably (64% for ante natal are and 36% for post-natal care compare to in the 55% for antenatal care and 27% for post Natal care in 2011) in 2014.

he answer to the question seems simple, most of the success happened due the evolution private sector in the area health. I am not saying this is bad but the issue is how the private sector is dealing with patients. The recent increase is perhaps due to private nursing homes where 80 percent of the total deliveries are carried out by C-section.

One case study will be able to demonstrate the motive of the private sector.

Zamila -I was pregnant with her third child. She had C-sector for the second child as she had placenta previa. Zamila was told to have the C-section for the third child as the doctor would not take any as the pregnant mother is short and diabetic. Zamila’s doctor left for Pilgrim (Hajj) duing her last trimester referring Zamila to another gynecologist for her remaining ante natal care/check up. When Zamila went for the check up to the new doctor, during the check up the doctor suggested zamila to go for an ultrasound on the following day and get admitted into clinic following ultrasound as the baby may die while mother is diabetic. With great dissatisfaction with the doctor and the checkup, Zamila refused to go for an ultra sound on the following day and get admitted in the clinic. The assistant to the doctor insisted Zamila to abide by doctor’s advice.

To understand the physical condition of the baby, Zamila decided to see another gynecologist. Almost similar things happened. She suggested the same, “as there will be Eid holiday and most of the doctors and nurse would be on leave, hence better to get admitted now”. At this stage Zamila decided to go for an ultrasound. It appeared from ultra sound that the baby was doing fine and Zamila could wait until the delivery date (two weeks from ultra sound date and when her original doctor would return ) but only she would know about her own health as this was her third pregnancy, whether she was feeling bad/uncomfortable to be admitted to hospital/clinic. Zamila waited until her delivery date and finally the C-section was done on due date by the original gynecologist. C-section is generally done when normal delivery is not possible, or when life-threatening problems are anticipated for both mother and foetus. Anecdotal evidence show that in most cases when women go for the first check up during pregnancy, the doctor advice C-section and the pregnant women often do not question that decision. The recent increase is due to private nursing homes where 80 percent of the total deliveries are carried out by C-section.

 

The UN health agency says there is no justification for any country to have C-section accounting for more than 10-15 percent of the total births. Bangladesh Demographic and Health Survey (DHS) found 23 percent births through C-section in 2014, six percentage points higher than the 2011 data. Of the total 37 percent births at health facilities in Bangladesh, 22 percent are delivered at private facilities, according to the DHS. C-section accounted for 4 percent of the child births in 2004, 9 percent in 2007, before rising to 17 percent in 2011 and the current level of 23 percent in 2014. According to international recommendations, caesarian sections are medically indicated in only 10 percent to 15 percent of deliveries But 80 percent of all deliveries in private facilities were caesarean. This rising trend of C-section is very alarming. Several factors are responsible for this.

  • There is no moral for the doctors. The behavior and attitude of the health service providers in private sector are motivated by money. Or most of the private hospital clinics are highly profit driven.
  • Doctors are becoming very commercial. The charge for the delivery package in the private clinics is very high, ranging from Tk.20,000- Tk.100,000 depending on the types of clinic. As clients get richer, the C-section rates go up. 
  • People are not aware about their rights, especially women no matter whether they are educated or not. They do not ask question. Lack of male involvement in the reproductive/maternal health care is another issue.
  • Many women are not willing to bear the labour pain which gives service providers an opportunity.
  • Lack of monitoring from government side on the operation of private nursing homes/clinics due absence of proper rules and regulations.

Technical Meeting on Women’s Health in the WHO European Region 2017-2021

 By- 

Stijntje Dijk, International Federation of Medical Students’ Associations (IFMSA)

LME@ifmsa.org
“There can be no health equity without addressing the determinants, gender inequities and making the right to health a reality. We are still missing a lot of policies that take a gender-based approach.” – WHO Europe

This March, the International Federation of Medical Students’ Associations (IFMSA), representing medical students worldwide, was present during the Technical meeting on women’s health in the WHO European Region 2017-2021, hosted by WHO Europe. During the meeting, civil society organizations joined the discussion on the draft strategy that will be finalized and presented to member states this April.
While the world has achieved progress towards gender equality and women’s empowerment under the Millennium Development Goals (including equal access to primary education between girls and boys), women and girls continue to suffer discrimination and violence in every part of the world. [i]

Women in the WHO European Region have better health than those in most countries of the world, but inequities are increasing for men and women within and between countries in the Region. [ii] Gender equality is not only a fundamental human right, but also a necessary foundation for a peaceful, prosperous and sustainable world. Health inequities among women remain large and unjustifiable. This is recognized in the WHO report, Beyond the mortality advantage. [iii] The report and the discussions during the technical briefing at the WHO regional committee for Europe in September 2015, together with the commitments expressed 20 years ago through the Beijing Platform for action [iv], and the Programme of Action of the International Conference for Population and Development[v], triggered the draft on the strategy on women’s health that has been drafted in coordination with a regional action plan on sexual and reproductive health.
The vision the strategy aims to achieve is that all girls and women are enabled and supported in achieving their full health potential and well-being, with their human rights respected, protected and fulfilled, and in which countries, both individually and together, work towards reducing gender and socioeconomic inequities in health within the region.

The strategy is supported by the values of the European policy framework for health and well-being, health 2020, which acknowledges that gender is a determinant of health, alongside social and environmental determinants. [vi] Gender-responsive health systems ensure that the links between biology, gender and social determinants are addressed across their functions. [vii]

The strategy aims to address women’s health issues beyond the reproductive health system or seeing women as mothers (-to-be) only. The Women’s health transformative agenda addresses human rights, equity, gender, life course, intersectional approaches and participation.

The most striking imbalance of power between women and men is the presence in all countries of violence against women, being a human rights violation and major obstacle to gender equality. Violence has serious and long-term effects on women’s physical and mental health through direct and indirect pathways, leading to physical and psychological trauma, stress, fear and a host of health and well-being problems. [viii] Additionally, residence (rural or urban), minority status and disabilities are also important dimensions that need to be taken into account when looking at inequalities in women’s health. Specific processes such as climate change, conflict situations, migration and human trafficking create additional vulnerable situations to ill health and have shown to majorly affect women. [ix]

During the technical briefing, civil society organizations including the IFMSA addressed the strategy in 4 areas:
– Governance (engendered policy making, women participation, impact assessment, intersectional approach to gender stereotypes and accountability)
– Discrimination (Policies valuing girls, health providers capacity, transformative health promotion and institutional bias
– Impact of determinants (multiple vulnerabilities, improving physical environment, interlinks between biology, gender and determinants, mental health-NCDs-healthy aging, unpaid care contributions, gender wage and pension gap)
– Responsive health systems (women’s health not being equal to motherhood, care for caregivers, gender transformative models, health sector as a role model: equity at the workplace, gender based medicine)

IFMSAs major input on the strategy focused on the need for empowering both the current as well as the future health workforce to address issues in women’s health, putting health in the perspective of being a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity. [x] IFMSA has many times before addressed the needs for Social Determinants of Health, human rights, health systems and global health education to be included in an effective manner in the formal medical curriculum. Additionally, continuous professional development programs should support current health professionals to understand the implications of SDH and to effectively work in the country’s health system to ensure all necessary care is provided.

The strategy will be further developed by WHO Europe and will produce an additional comprehensive report this July.

“We embark now on an action plan, we want to make sure the action plan will lead to us to national implementation. Let us know your engagement as civil society, where do you see your strength, and how can you use this strategy as a good advocacy tool.” – WHO Europe.

(This blogpost was originally posted at http://ifmsa.org/2016/03/19/technical-meeting-on-womens-health-in-the-who-european-region-2017-2021/ )

About IFMSA:
The International Federation of Medical Students’ Associations (IFMSA), founded in 1951, is the worlds largest medical student organization. It represents, connects and engages daily with a network of 1.3 million medical students from 119 countries around the world.
IFMSA brings people together to exchange, discuss and initiate projects to create a healthier world. It gives its members the skills and resources they need to be health leaders. It advocates for pressing issues that matter to shape the world we want. Our projects, campaigns and activities aim to positively physicians-to-be and the communities we serve.

References:

[i] Sustainable Development Goal 5: Achieve gender equality and empower all women and girls; http://www.un.org/sustainabledevelopment/gender-equality/
[ii] Health 2020: a European policy framework supporting action across government and society for health and well-being. Copenhagen: WHO Regional Office for Europe; 2012 (EUR/RC62/9; http://www.euro.who.int/en/health-topics/health-policy/health-2020-the-european-policy-for- health-and-well-being/publications/2013/health-2020-a-european-policy-framework-supporting-action-across-government-and-society-for- health-and-well-being, accessed 24 July 2012).
[iii] Beyond the mortality advantage: investigating womens health in Europe. Copenhagen: WHO Regional Office for Europe; 2015 (http://www.euro.who.int/en/health-topics/health- determinants/gender/publications/ 2015/beyond-the-mortality-advantage.-investigating-womens-health-in-europe).
[iv] Fourth World Conference on Women. Beijing Declaration and Platform for Action [website]. New York (NY): UN Women; 2015 (http://www.un.org/ womenwatch/daw/beijing/platform/, accessed 24 July 2015).
[v] Programme of action adopted at the International Conference on Population and Development, Cairo, 5?13 September 1994: 20th anniversary edition. New York (NY): United Nations Development Programme; 2014 (http://www.unfpa.org/publications/international-conference-population- and-development-programme-action/, accessed 24 July 2015).
[vi] Health 2020: a European policy framework supporting action across government and society for health and well-being. Copenhagen: WHO Regional Office for Europe; 2012 (EUR/RC62/9; http://www.euro.who.int/en/about- us/governance/regional-committee-for-europe/past-sessions/sixty-second- session/documentation/working-documents/eurrc629-health-2020-a-european- policy-framework-supporting-action-across-government-and-society-for-health- and-well-being).
[vii] Draft Strategy on womens health in the WHO European Region 2017?2021. Version 15 February 2016
[viii] Global and regional estimates of violence against women: prevalence and health effects of intimate partner violence and non-partner sexual violence. Geneva: World Health Organization; 2013 (http://apps.who.int/iris/bitstream/10665/85239/1/9789241564625_eng.pdf, accessed 24 July 2015).
[ix] Beyond the mortality advantage: investigating womens health in Europe. Copenhagen: WHO Regional Office for Europe; 2015 (http://www.euro.who.int/en/health-topics/health- determinants/gender/publications/ 2015/beyond-the-mortality-advantage.-investigating-womens-health-in-europe).
[x] World Health Organization Constitution (1948), Definition of health.

Women have a right to medical privacy

RIGHTS: Women seeking abortion services should have their medical privacy respected and not have to encounter protestor groups.

RIGHTS: Women seeking abortion services should have their medical privacy respected and not have to encounter protestor groups.

AUSTRALIA – Victoria’s abortion law reform and safe access legislation enacted on Monday ensures women have the right to a safe and legal abortion service without intimidation or violation of medical privacy.

Sadly, women living in North East Victoria who attend the Albury Fertility Control Clinic are not protected and still face the threat of harassment and shaming from protesters.

In some cases this affects women from just across the Border. It is just six kilometres from the Albury clinic to Wodonga’s city heart but the two states’ laws in regards to safe medical care and privacy are worlds apart.

Safe access to sexual and reproductive health services, including abortion, is good public health practice and plays an important role in supporting women’s broader health and wellbeing.

Women experiencing unplanned or unwanted pregnancies are often already feeling distressed, isolated, anxious and fearful. Being confronted by anti‐abortion groups at an already difficult, sensitive and personal time exacerbates these feelings.

It is intimidating and demeaning for women to have to run the gauntlet of anti‐abortion groups in order to access essential health care and services – that can be terminations but also other procedures offered at clinics such as dilation and curettage after miscarriage or even contraception advice and STD screening.

Targeting health services in this way can have impacts on women’s health and wellbeing. Health services have reported that some patients are too afraid to attend clinics when anti‐abortion groups are out the front, or to return for follow‐up appointments because of their earlier experience.

The negative impacts of anti-abortion protesters on women, their supporters and clinic staff is strongly affirmed in the 2008 Victorian Law Reform Commission report which told of a woman who described her own experience as one where she was in “no position to defend myself from such a cowardly attack at a vulnerable time in my life”.

The Victorian Women with Disabilities Network also noted women with disabilities use clinics for a variety of reproductive health services. In the report a medical practitioner, who claimed to have received a death threat, said one of the reasons for local specialists in regional areas not performing abortions is the concern about verbal or physical attacks.

According to the World Health Organisation’s technical and policy guidance for safe abortion, the fear confidentiality will not be maintained deters many women from seeking safe, legal abortion services, and may drive them to clandestine, unsafe abortion providers, or to self‐induce abortion.

Research undertaken in 2011 by rural Women’s Health services shows women living in North East Victoria already face significant barriers to sexual and reproductive health care and services.

With few specialist pregnancy counselling and termination services available, rural women frequently travel considerable distances to Melbourne or Albury to access reproductive health and abortion services. To turn this around abortion must be decriminalised and exclusion zones legislated in NSW. It’s time for NSW MPs to ensure women’s rights to reproductive health care and services and to treat them with privacy and respect. http://www.bordermail.com.au/story/3891637/women-have-a-right-to-medical-privacy/

Training Health Professionals to Reduce Violence against Women -The Ananya Project

 

Authors- Prof. Surekha Tayade, Prof. Judy Lewis

surekha

facilitators, Prof Judy Lewis (left ), Dr Surekha Tayade (right )

The Department of Obstetrics and Gynecology, Mahatma Gandhi Institute of Medical Sciences, Sewagram, Wardha, India organized a one-day training workshop for health care professionals working in the field of women’s health to increase awareness and examine the skills and strategies to address violence against women (VAW).    The workshop on 6th March 2016 was attended by 40 participants, including consultants and residents from Obstetrics and Gynecology, residents from Community Medicine and Forensic Medicine Departments and nursing professionals.

The Convener for the workshop was Prof. Surekha Tayade,who conducted the workshop with Prof. Judy Lewis and Prof. S Chhabra—all three are active members of the  Women and Health Task Force. Prof. Lewis is from the University of Connecticut, USA, and is a VAW expert with years of experience in women’s health projects, counseling and advocacy programs., Prof. S Chhabra and Prof.Surekha Tayade are both experienced clinicians with expertise in VAW.

The workshop was part of activities leading up to a community survey to assess the prevalence and community attitudes about VAW in order to develop effective community interventions to prevent and treat VAW.  The workshop also coincided with International Women’s Day activities, and Prof. Tayade organized nursing and medical students to give short dramas about VAW.  These were performed at the hospital on April 8th (International Women’s Day) and will be part of the community program.

Health workers have a crucial role to play in helping women and children who experience violence. Those working in the community, in health centers and clinics, may hear rumors that a woman is being beaten or a child abused, or notice evidence of violence when women seek treatment for other conditions. Those working in hospital emergency departments may be the first to examine women injured by rape or domestic violence. Health workers visiting institutions such as prisons, mental hospitals and retirement homes may be the only source of outside help for victims of abuse. The problem of violence against women is enormous and troubling. There are no easy answers. The health sector cannot solve it alone. Still, with sensitivity and commitment, it can begin to make a difference

Most health workers have neither the time nor the training to assume the full responsibility of meeting the needs of women who have been abused.

At a minimum, health workers can(WHO 2013) :

• First, “do no harm”. Unsympathetic or victim-blaming attitudes can reinforce isolation and self-blame, undermine women’s self confidence, and make it less likely that women will reach out for help.

• Be attentive to possible symptoms and signs of abuse and follow up on them.

• Where feasible, routinely ask all clients about their experiences of abuse as part of normal history taking.

• Provide appropriate medical care and document in the client’s medical records instances of abuse, including details of the perpetrator.

• Refer patients to available community resources.

• Maintain the privacy and confidentiality of client information and records.

surekha2

Group discussion and interactive participation

This workshop was conducted with the goal of improving awareness about the dynamics of violence against women and improve prevention, screening, identification and treatment.  This was accomplished through various activities: to exchange best practice examples between the participants, and to build the capacity of the participants to recognize various forms and patterns of  violence, sympathize with the plights of the victim/ survivor, discuss the impact of violence on women, institutes and the community and suggest solutions to the problem .

This was an interactive workshop beginning with introductions and expectations of participants about the workshop, followed by a basic VAW and domestic violence, in particular. Using a combination of presentations and exercises, the facilitators helped the participants to understand the dynamics of domestic violence, and to become aware of its intrinsic patterns. The gender biased nature of abuse was highlighted as well as the links between violence against women and patriarchal social structures.

surekha3

Student play about VAW in maternity wards

The importance of using a gendered perspective and victim-centred approach in service provision was stressed as participants were asked to reflect and share about the plight of the survivor and how to be empathetic.A group activity was conducted to discuss the impact of violence on the women, her family, and the community and how policies can be created or adjusted to better assist victims of domestic violence. In particular, the connection between abuse of the mother and the abuse of children was discussed—even if children do not directly experience physical violence, as witnesses of violence against the mother, children are also victims.

Participants shared solutions in local context, taking into consideration the intricate social framework of the Indian rural community. The workshop ended with feedback and evaluation.

 

surekha4

Feminist Mary Hames – South Africa- Progressive Rights or Mechanisms of Control ?

By –  Kamayani Bali Mahabal

Mary Hames, Director Gender Equity Unit , University of Western Cape (UWC), while delivering her plenary presnetation at the Towards Unity for Health (TUFH ) International conference on Public Health in Pretoria , in September 2015 said that The feminist intellectual activism that I am involved in, made me acutely aware of how the engineering of policies and laws impact on the outcome of women’s health and well-being. But let me start with how the post-1994 South African democracy introduced on of the most progressive pieces of feminist legislation – the Choice on the Termination of Pregnancy Act 92 of 1996. The only one on the African continent and some of the global North countries still do not want to conceive (no pun intended) the notion of ‘Choice’ that women have over their bodies and reproductive health.
Tracing the journey of promulgation of this piece of historic law , she said ‘ It was not easy. The ruling ANC was not as benevolent and some of the members did not come to parliament on the day of the vote and others abstained ostensibly for religious and other reasons. The Christian Lawyers Association instituted a case against the Minister of Health arguing that the Act is in contradiction to the ‘right to life clause’ in the Constitution while there has been a strong argument for the ‘right to make decisions concerning reproduction’. There are also medical professionals and practitioners that oppose termination of pregnancy such as Doctors for Life International that stands for amongst others “the sanctity of life from conception till death”.

 

maryhames
Mary Hames, who was invited by the Womens Heallth Task force (WHTF ) at conference said that , ‘ The Part of the victory of ‘choice’ was that women did not have to consult partners, husbands or parents they had now what feminists been fighting for autonomy over their bodies. Our language should be about ‘reproductive justice’.
It is said that the South Africa’s Primary Healthcare system has ‘revolutionised’ the public healthcare for pregnant women and for children up to the age of six. Access to reproductive health care was granted as well as the provision of free contraception and the termination of pregnancy.  The intersections of race, class, gender and sex have an instrumental role in the access to this very progressive health system. Various factors came into play and soon termination of pregnancy for those women who needed it most became open to abuse.
For instance, there was the opening up of an unscrupulous ‘abortion industry’ where at no stage they involve a medical practitioner; the procedure is concluded by unqualified persons; the 1996 Act did not make provision for penalties; the requisite counselling is not provided; informed consent is very seldom obtained and the list of abuses is long.
In an effort to close the loopholes in the growing ‘abortion industry’ the Choice on the Termination Amendment Act No. 38 was promulgated in 2004. At present it seems like a losing battle as reports abound of how illegal abortion providers advertise their services on trains, lamp posts, on the side of garbage cans outside one of the biggest public hospitals in Cape Town.

Some of these stickers read ‘1 to 8 months Safe Abortion Pills’.Nevertheless, there already exists a lucrative market for ‘backstreet’ termination. There is great myth building and urban legends around the termination of pregnancy. Some women are under the impression that legal terminations are too expensive and this is an indication that there is very little knowledge about the existing legal framework.
But it is not only the ‘illegal operators’ that are implicated, but even health professionals often find it difficult to separate their personal beliefs from the service that they should legally provide.
The personal politics of many healthcare workers are at odds with the legal commitment and the public health imperative to provide comprehensive reproductive healthcare, including abortion.The denial of analgesics [pain medication] to abortion patients may sometimes be used to punish women for having abortions and to discourage them from seeking ‘repeat’ abortions
Referring to law and medicine , she said Both disciplines are deeply embedded in patriarchal structures and language. It is because of women’s subjugated position in society that women’s bodies are particularly susceptible to violence, sexually transmitted diseases and unwanted pregnancy . As feminists we are working tirelessly to raise consciousness in order to engender the law so that women could find recourse when their bodies have been violated. Although the language of the law has become more inclusive, the equality that has been fought for has become more elusive, she said with hint of cynicism in her tone.

‘In South Africa, women and particularly lesbian women have changed the jurisprudence to make it more accessible for all women. Foreg : in vitro fertilization – in this instance lesbians have been litigating to obtain the right to artificial insemination – before this a heterosexual woman had to gain the permission from her husband to artificially conceive. Although we hail this as a great step for all women clinics specialising egg harvesting have started to financially exploit the infertility of women and egg harvesting became big business. The targets for harvesting are young university students who are paid enormous sums of money for their.

Referring to surrogacy, she poinetd that it had o changed the notion of parenthood and family something that had a profound effect on the conservative religious sector. Same-sex couples could now benefit from these procedures. Medical tourism has grown by leaps and bounds.Other examples include the Domestic Violence Act and the Sexual Harassment Policy and Maternity leave which have been conceived and implemented in very negative environments for women. All of these laws and policies have by their very nature also included everyone else and not only women, she added
.
Speaking on impact of health care for Transwomen. , Ms hames chose to use Spivak’s notion of political essentialism while speaking  of woman/women, gender and sex.
‘ Today we are seeing Control and surveillance of women’s bodies, The young  south african women students are being demonised as hyper-sexualised in recent research with regard to HIV and AIDS. ‘ she said adding that ‘Firstly, through the free supply of male condoms in almost every space even in women’s public toilets as if they are responsible to safe guard men against diseases that the women’s bodies carry – they could not find any free female condom or even a free sanitary towel in their toilets.’
‘Secondly, the fact that many young women are implanted with the contraceptive Implanon – especially government bursary holders for overseas studies. This contraceptive is free irrespective of public or private healthcare. Initial investigation shows that schoolgirls are also receiving the implant ostensibly because they are sexually active and to reduce child mortality and improve maternal health.’, she noted.
She also pointed that Government Health Departments have also started to inoculate thousands of schoolgirls between the ages of 9 and 11 to prevent them from getting the human papilloma virus (HPV). There is the assumption that these young girls are susceptible to cervical cancer. Feminists are still debating the pros and cons of this procedure and the impact on women’s bodies, she added

Mary Hames , talking about medicalization of women’s bodies said ‘ Doctors have the underlying understanding that there is something inherently wrong with our bodies and this must be remedied – scientific research and pharmaceutical companies take advantage of these insecurities that are thus created and internalised. Hormone Replacement Therapy (HRT), ceasarian sections, other elective surgery and so forth and because these are expensive endeavours these procedures become highly dependent on income, class and convenience.’ We need to  question the medicalization of birth and advocated for listening and learning from women.
Referring to Ethics ain raesearch she said ‘ ALL research should be responsible and accountable and that women’s agency should be central to any research project. Medical research have largely responsible in making women’s bodies prime sites for research projects. We have come to be introduced to the ‘ideal’ body weight; we are told why we are susceptible to particular diseases, in South Africa and other Developing Countries less affluent women have become the objects in the HIV and AIDS research industry. At public clinics black pregnant women are targeted for focus groups research, they are injected with placebo because they are more dispensable to society. ’
Ridiculing the The United Nations call for ‘gender mainstreaming’ , she said it ended up in ‘gender male streaming’.’ ‘In my opinion the strides that women made by identifying their particular struggles and multiple positionalities were steadily erased by the binary understanding of gender and sex. The main question now becomes the male question.
We often hear gender includes men. Men and boys are left behind. In South Africa, Sisonke Gender Justice, became the self-appointed defender of women’s rights and spokes organisation. They are the ‘good men’ speaking on our behalf. And of course, the funding has been channelled to the ‘good men’, our ‘protectors’ and women’s organisations have started to close down. The neo-liberal patriarchy has descended upon us.

In spite of the ‘progressive’ 1996 Constitution, it took the LGTBI (Lesbian Gay Transgender Bisexual and Intersex) community years to systematically litigate against the discriminatory legal framework. Bias and prejudice in the health care system continues and this leads to the inadequate assessment, treatment and prevention of health issues.
Stereotyping, stigmatisation and prejudice often leads to the inadequate provision of health care. Cultural and religious barriers are painful experiences to lesbian and transgender women. Bias can lead to ignorance of preventative care for instance pap smears for lesbians or pain management for genital post-surgery. ‘We think and act differently about the impact of advances of the so-called women-sensitive laws because there has been less vigour in the proper application thereof. Also, as I have mentioned many of these laws have been designed within a negative paradigm, she concluded

India endorses ‘Respectful Maternity Care’ charter for the country on Safe Motherhood Day

Kamayani Bali Mahabal, India

Every year 45,000 women die in India in pregnancy and childbirth. Eliminating disrespect and abuse during maternity care can significantly reduce the health risks pregnant women face.

Every year on April 11, India observes National Safe Motherhood Day so that citizens, communities and other stakeholders take a pause and deliberate on the maternal health situation and look at what interventions are working and what more is needed to be done.

This year to highlight the right of every woman to quality maternal health services, the White Ribbon Alliance India (WRAI) endorsed the Respectful Maternity Care (RMC) Charter which demonstrates the legitimate place of maternal health rights in the broader context of human rights. The charter has already been adopted in Nigeria and Nepal.

Government officials, elected representatives and civil society advocates assembled under a single roof on the occasion to bring attention to safe motherhood. At the event the Respect for Maternity Care Charter was unveiled. The Charters has 7 basic principles that state the right of women to be free from abuse, right to consent on their treatment, right to privacy, right to dignity and respect, right to freedom from discrimination, access to healthcare and right to liberty.

 

The Distinctive Importance of the Childbearing Period

In every country and community worldwide, pregnancy and childbirth are momentous events in the lives of women and families and represent a time of intense vulnerability. The concept of “safe motherhood” is usually restricted to physical safety, but childbearing is also an important rite of passage, with deep personal and cultural significance for a woman and her family. Because motherhood is specific to women, issues of gender equity and gender violence are also at the core of maternity care. Thus, the notion of safe motherhood must be expanded beyond the prevention of morbidity or mortality to encompass respect for women’s basic human rights, including respect for women’s autonomy, dignity, feelings, choices, and preferences, including choice of companionship wherever possible.

By design, this document focuses specifically on the interpersonal aspects of care received by women seeking maternity services. A woman’s relationship with maternity care providers and the maternity care system during pregnancy and childbirth is vitally important. Not only are these encounters the vehicle for essential and potentially lifesaving health services, women’s experiences with caregivers at this time have the impact to empower and comfort or to inflict lasting damage and emotional trauma, adding to or detracting from women’s confidence and self‐esteem. Either way, women’s memories of their childbearing experiences stay with them for a lifetime and are often shared with other women, contributing to a climate of confidence or doubt around childbearing.

Growing Evidence of Disrespect and Abuse

Imagine the personal treatment you would expect from a maternity care provider entrusted to help you or a woman you love give birth. Naturally, we envision a relationship characterized by caring, empathy, support, trust, confidence, and empowerment, as well as gentle, respectful, and effective communication to enable informed decision making. Unfortunately, too many women experience care that does not match this image. A growing body of anecdotal and research evidence collected in maternity care systems from the wealthiest to poorest nations worldwide paints a different and disturbing picture. In fact, disrespect and abuse of women seeking maternity care is becoming an urgent problem and creating a growing community of concern that spans the domains of healthcare research, quality, and education; human rights; and civil rights advocacy.

In 2010, a landscape report by Bowser and Hill, Exploring Evidence for Disrespect and Abuse in Facility‐based Childbirth, summarized the available knowledge and evidence on this topic.i While the review revealed a relative lack of formal research on the topic, the authors’ in‐depth search of published and technical literature as well as interviews and discussions with content experts described seven major categories of disrespect and abuse that childbearing women encounter during maternity care. These categories overlap and occur along a continuum from subtle disrespect and humiliation to overt violence; they include physical abuse, non‐consented clinical care, non‐confidential care, non‐dignified care (including verbal abuse), discrimination based on specific patient attributes, abandonment or denial of care, and detention in facilities.

Interpersonal care that is disrespectful and abusive in nature to women before, during, and after birth is appalling because of the high value societies attach to motherhood and because we know the intense vulnerability of women during this time. All childbearing women need and deserve respectful care and protection of their autonomy and right to self‐determination; this includes special care to protect the mother‐baby pair as well as marginalized or highly vulnerable women (e.g., adolescents, ethnic minorities, and women living with physical ormental disabilities or HIV). Furthermore, disrespect and abuse during maternity care are a violation of women’s basic human rights.

Assertion of the Universal Rights of Childbearing Women

Human rights are fundamental entitlements due to all people, recognized by societies and governments and enshrined in international declarations and conventions. To date, no universal charter or instrument specifically delineates how human rights are implicated in the childbearing process or affirms their application to childbearing

women women

as basic, inalienable human rights. This Charter aims to address the issue of disrespect and abuse among seeking maternity care and provide a platform for improvement by

  •   Raising awareness of childbearing women’s inclusion in the guarantees of human rights recognized in internationally adopted United Nations and other multinational declarations, conventions, and covenants;
  •   Highlighting the connection between human rights language and key program issues relevant to maternity care;
  •   Increasing the capacity of maternal health advocates to participate in human rights processes;
  •   Aligning childbearing women’s sense of entitlement to high‐quality maternity care with internationalhuman rights community standards; and
  •   Providing a basis for holding the maternal care system and communities accountable to these rights.By drawing on relevant extracts from established human rights instruments, the Charter demonstrates the legitimate place of maternal health rights within the broader context of human rights. Seven rights are included, drawn from the categories of disrespect and abuse identified by Bowser and Hill (2010) in their landscape analysis (see table). All these rights are grounded in international or multinational human rights instruments, including the Universal Declaration of Human Rights; the Universal Declaration on Bioethics and Human Rights; the International Covenant on Economic, Social and Cultural Rights; the International Covenant on Civil and Political Rights; the Convention on the Elimination of All Forms of Discrimination Against Women; the Declaration of the Elimination of Violence Against Women; the Report of the Office of the United Nations High Commissioner for Human Rights on preventable maternal mortality and morbidity and human rights; and the United Nations Fourth World Conference on Women, Beijing. National instruments are also referenced if they make specific mention of childbearing women. Each right is sourced to the relevant instruments.ii

     

In seeking and receiving maternity care before, during, and after childbirth:

ARTICLE I: Every woman has the right to be free from harm and ill treatment

International Standards

  •   Declaration of the Elimination of Violence Against Women, 1994, Article 1
  •   International Covenant on Civil and Political Rights (ICCPR), 1966, Article 7
  •   International MotherBaby Childbirth Initiative: A Human Rights Approach to Optimal Maternity Care, 2010,Article 9
  •   International Planned Parenthood Federation Charter on Sexual and Reproductive Rights, 1996, Article 12
  •   Universal Declaration on Bioethics and Human Rights, 1997, Article 4

Multinational and National Standards

  •   European Charter of Patient’s Rights, 2002, Article 9
  •   Ley Orgánica sobre el Derecho de las Mujeres a una Vida Libre de Violencia de Venezuela, 2007, Article 15j

ARTICLE II: Every woman has the right to information, informed consent and refusal, and respect for her choices and preferences, including the right to her choice of companionship during maternity care, whenever possible

International Standards

  •   International Covenant on Civil and Political Rights (ICCPR), 1966, Article 7, 19
  •   International Planned Parenthood Federation Charter on Sexual and Reproductive Rights, 1996, Article 6
  •   International MotherBaby Childbirth Initiative: A Human Rights Approach to Optimal Maternity Care, 2010,Article 3, 4
  •   Report of the Office of the United Nations High Commissioner for Human Rights on preventable maternalmortality and morbidity and human rights, 2010
  •   Universal Declaration on Bioethics and Human Rights, 1997, Article 6

Multinational and National Standards

  •   Birth Justice as Reproductive Justice, NAPW, 2010
  •   Charter of Fundamental Rights of the European Union, 2000, Article 3.2, 7
  •   Convention for the Protection of Human Rights and Dignity of the Human Being with regard to theApplication of Biology and Medicine: Convention on Human Rights and Biomedicine, 1997, Article 5
  •   Declaration on the Promotion of Patients’ Rights in Europe, 1994, Articles 1.5, 2, 3, 4.6, 5
  •   European Charter of Patient’s Rights, 2002, Article 3, 4, 5, 12
  •   Ley de Acompañamiento durante el Trabajo de Parto, Nacimiento y Post‐parto de Puerto Rico, 2006,Article 3e, 3f
  •   Ley de Parto Humanizado—Ley Nacional No. 25.929 de Argentina, 2004, Article 2f, 2g
  •   The Rights of Childbearing Women, Childbirth Connection 1999, 2006, Articles 3, 4, 5, 6, 9, 12, 13, 14, 16, 19

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ARTICLE III: Every woman has the right to privacy and confidentiality

International Standards

  •   International Covenant on Civil and Political Rights (ICCPR), 1966, Article 17
  •   International Planned Parenthood Federation Charter on Sexual and Reproductive Rights, 1996, Article 4
  •   Universal Declaration on Bioethics and Human Rights, 1997, Article 9

Multinational and National Standards

  •   Declaration on the Promotion of Patients’ Rights in Europe, 1994, Article 1.4, 4
  •   European Charter of Patient’s Rights, 2002, Article 6
  •   The Rights of Childbearing Women, 1999, 2006, Article 7

ARTICLE IV: Every woman has the right to be treated with dignity and respect

International Standards

  •   International Covenant on Civil and Political Rights (ICCPR), 1966, Article 2
  •   International MotherBaby Childbirth Initiative: A Human Rights Approach to Optimal Maternity Care,Article 1
  •   Report of the Office of the United Nations High Commissioner for Human Rights on preventable maternalmortality and morbidity and human rights, 2010
  •   United Nations Fourth World Conference on Women, Beijing 1995
  •   Universal Declaration on Bioethics and Human Rights, 1997, Article 8, 10, 11

Multinational and National Standards

  •   Birth Justice as Reproductive Justice, NAPW, 2010
  •   Charter of Fundamental Rights of the European Union, 2000, Article 1, 3, 7
  •   Convention for the Protection of Human Rights and Dignity of the Human Being with regard to theApplication of Biology and Medicine: Convention on Human Rights and Biomedicine, 1997, Article 1
  •   Declaration on the Promotion of Patients’ Rights in Europe, 1994, Article 1.1, 1.4, 1.5
  •   European Charter of Patient’s Rights, 2002, Article 7

ARTICLE V: Every woman has the right to equality, freedom from discrimination, and equitable care

International Standards

  •   Convention on the Elimination of All Forms of Discrimination against Women (CEDAW), 1979, Article 1
  •   International Covenant on Economic, Social and Cultural Rights (ICESCR), 1976, Article 2
  •   International Covenant on Civil and Political Rights (ICCPR), 1966, Article 26
  •   International Planned Parenthood Federation Charter on Sexual and Reproductive Rights, 1996, Article 3
  •   Report of the Office of the United Nations High Commissioner for Human Rights on preventable maternalmortality and morbidity and human rights, 2010
  •   United Nations Fourth World Conference on Women, Beijing 1995, Article 28
  •   Universal Declaration on Bioethics and Human Rights, 1997, Article 10, 11

Multinational and National Standards

  •   Charter of Fundamental Rights of the European Union, 2000, Article 21, 23
  •   Declaration on the Promotion of Patients’ Rights in Europe, 1994, Article 5.1

 

ARTICLE VI: Every woman has the right to healthcare and to the highest attainable level of health

International Standards

  •   Declaration of Alma Ata, International Conference on Primary Care, 1978, Preamble, Articles 4, 6
  •   International Planned Parenthood Federation Charter on Sexual and Reproductive Rights. 1996, Article 9
  •   Report of the Office of the United Nations High Commissioner for Human Rights on preventable maternalmortality and morbidity and human rights, 2010
  •   United Nations Fourth World Conference on Women, Beijing 1995
  •   Universal Declaration of Human Rights, 1948, Article 25
  •   Universal Declaration on Bioethics and Human Rights, 1997, Article 14.2

Multinational and National Standards

  •   Charter of Fundamental Rights of the European Union, 2000, Article 35
  •   Constitución Política del Estado Plurinacional de Bolivia, 2008, Article 45.V
  •   Convention for the Protection of Human Rights and Dignity of the Human Being with regard to theApplication of Biology and Medicine: Convention on Human Rights and Biomedicine, 1997, Article 3
  •   Declaration on the Promotion of Patients’ Rights in Europe, 1994, Article 5
  •   The Rights of Childbearing Women, 1999, 2006, Article 1

ARTICLE VII: Every woman has the right to liberty, autonomy, self-determination, and freedom from coercion

International Standards

  •   Declaration of the Elimination of Violence Against Women, 1994, Article 1
  •   International Covenant on Economic, Social and Cultural Rights (ICESCR), 1976, Article 1
  •   International Planned Parenthood Federation Charter on Sexual and Reproductive Rights, 1996, Article 2
  •   International Covenant on Civil and Political Rights (ICCPR), 1966, Article 9.1, 18.2
  •   Universal Declaration on Bioethics and Human Rights, Article 5

Multinational and National Standards

  •   Charter of Fundamental Rights of the European Union, 2000, Article 6
  •   Declaration on the Promotion of Patients’ Rights in Europe, 1994, Article 1.2

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This charter was developed collaboratively by a multi‐stakeholder group with expertise bridging research, educational, clinical, human rights, and advocacy perspectives. The following people contributed to this consensus document as members of a community of concern working in concert to address the issue of disrespect and abuse during maternity care within their various constituencies: