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The Power of Pills: Putting Abortion Back in the Hands of Women Around the World

4:02 pm in Uncategorized by RH Reality Check

Written by Leila Hessini and Alyson Hyman for RH Reality Check. This diary is cross-posted; commenters wishing to engage directly with the author should do so at the original post.

A collection of different pills

As governments force clinics out of business, pill-based abortions offer freedom of choice to women.

Unwanted pregnancies are a fact of life. Globally, nearly a fourth of all pregnancies are unplanned and 22 percent of pregnancies end in abortion. Women experience unwanted pregnancies because they have forced sex, (worldwide, one in three women are survivors of sexual violence), they don’t have access to contraceptives, or they simply didn’t plan on becoming pregnant.

Women who have unwanted pregnancies should be respected and their rights to choice upheld. However, in many countries, government policies, and societal practices do not uphold women’s right not to continue a pregnancy and women with unwanted pregnancies are forced into motherhood. Certainly this is evident in the United States; just before the new year, the governor of Virginia quietly signed legislation designed to close abortion clinics in the state. These laws are punitive, restricting women’s reproductive autonomy and freedom and creating categories of who can and can’t obtain abortions.

Fortunately for women, pills have changed the landscape of abortion. Abortion with pills, also known as medical abortion (MA), provides a safe, low-cost and easy to use method to terminate pregnancies. In addition to being safe and effective, medical abortion has changed the dynamics of who can provide abortions, where women get them, and who has control over the process. Evidence shows that those closest to women — community health workers and midwives — and women themselves can be trained to use abortion pills to safely terminate a pregnancy, thus giving women back the control of their own bodies. In fact, it was women in Brazil who first discovered the potential of misoprostol (cytotec) to safely end an unwanted pregnancy and who shared this knowledge through their social networks.

In order for women to benefit from the potential of medical abortion, however, they must be active participants in decisions related to where drugs are distributed and for what cost, what information is shared and by whom, and what social and medical support is needed.

Last month, Ipas hosted a meeting — “In Women’s Hands: Increasing Access to Medical Abortion Drugs and Information through Pharmacies and Drug Sellers” — in Nairobi, Kenya, that brought together 66 participants from 11 countries to discuss these important issues. Participants included a Kenyan hotline program manager, president of the Ugandan Midwives Association, several pharmacy managers from South Africa, and a Nepali senior public health officer in the Ministry of Health and Population, to name a few. The broad swath of countries and professionals represented illustrates commitment to a movement — to give women control of their reproductive lives, particularly through abortion with pills. In different countries, women, advocates and providers have developed innovative strategies to meet this goal.

In Tanzania, the Women’s Promotion Centre founded its own small pharmacy in a rural community as an alternative model for supporting women’s access to safe motherhood and abortion. This effort was born out of the “fire of anger about unnecessary deaths and suffering of women and… passion to save mothers’ lives in Kigoma,” said Martha Jerome of the Centre. Because no pharmacies were selling the lifesaving drug misoprostol, they founded a pharmacy to provide the drug themselves. They trained staff to provide counseling and support and they formed an alliance with like-minded doctors to help women with any complications. They also supply contraceptives as well as other medicines. The competition that resulted from their lower prices has driven down the cost from other private drug sellers, making these medicines more affordable for women who need them.

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“It was Worth the Sacrifice:” Kenya’s Dr. John Nyamu on Why He Spent a Year in Prison

1:59 pm in Uncategorized by RH Reality Check

Written by Mary Fjerstad for RH Reality Check. This diary is cross-posted; commenters wishing to engage directly with the author should do so at the original post.

Cross-posted with permission from Ipas.

This article was also published in Medical Abortion Matters (November 2012).

Until 2011, abortion was illegal in Kenya except to save a woman’s life. For years the climate of fear and secrecy surrounding abortion hurt women, their families, and health-care providers. Unsafe abortion in Kenya still causes an estimated 30 percent of maternal deaths and countless other injuries.

Now, a newly ratified Kenyan constitution allows for legal abortion on much broader terms — and, when the new law is fully implemented, it stands to dramatically increase women’s ability to exercise their reproductive rights.

Ipas’s senior clinical advisor Mary Fjerstad recently sat down with Kenya’s much-respected Dr. John Nyamu to discuss the long and difficult path he and so many other Kenyans have traveled to get where they are today.


Mary Fjerstad: Doctor Nyamu, would you tell me what the situation was like in Kenya when abortion was considered a criminal act? [Editor's note: Before constitutional reform, abortion in Kenya was highly restricted with few legal indications for having the procedure.]

Dr. John Nyamu: Most health-care workers were afraid of talking about it openly. Abortion was never performed in government hospitals unless the life of the woman was in real danger. Even then it was very bureaucratic as one doctor could only do the procedure with permission in writing from two other doctors; one doctor had to be a psychiatrist and the other doctor had to be a senior doctor in the hospital. Abortions were performed by D&C or induction. In reality, these legal abortions were provided almost exclusively at Kenyatta National Hospital, provincial hospitals and very rarely in district hospitals. (Kenyatta National Hospital is the major teaching hospital in Nairobi).

There were wards in hospitals where women who had unsafe abortions were treated for uterine and bowel damage due to perforations and developed sepsis, brain damage and many women died.

There was tremendous secrecy about abortion, women were aborting late. The penalty for a doctor who performed an [illegal] abortion was 14 years [in prison]; pharmacists could be imprisoned for three years for giving abortifacient medicines and women themselves could be imprisoned for seven years for having an abortion.

Some private clinics were providing safe abortion. They were harassed regularly by local police, usually by extortion. They were used virtually as the personal ATMs of the police [ATM = Automatic Teller Machine, a banking machine from which you can withdraw cash using a bank card]. A policeman would say, “I’m short of cash, give me your cash or I’ll arrest you.” The entire staff, including nurses, doctors and women seeking abortion could be arrested. Due to the fear, the providers kept servicing [the police] to buy their freedom.

Your case was profiled by The Center for Reproductive Rights’ paper in 2010, “In Harm’s Way: the Impact of Kenya’s Restrictive Abortion Law.” Can you briefly describe what happened to you that led to this paper?

In 2004, [data were shared] which showed worrying trends and consequences of unsafe abortion in Kenya. This was followed by a major crackdown on clinics, hunts for women who had abortions, some clinics were closed and I was targeted. There were 15 fetuses found along a major road with some documents from a hospital I had worked at previously but had since closed. My clinic was raided and two nurses and I were arrested. This appeared to have been very well organized with all the media including print, radio and TV present to report on the matter.  When we were asked to pay bribes, we refused — because we knew the fetuses were not from our clinic and the documents were planted on the road — and we were locked up. [Editor's note: subsequent pathology examinations found that the fetuses were still-born fetuses, not aborted fetuses.]

The three of us were ultimately charged with two counts of murder, rather than an abortion-specific offense. Since murder is a non-bailable offense in Kenya, we had to stay in remand prison pending our trial. We all spent a year in prison. One of the nurses was six months pregnant and delivered while she was in prison. One of the nurses still works for me and the other got her green card and has since immigrated to the United States.

A senior doctor, a gynecologist, was instructed by the Director of Medical Services of the Ministry of Health to accompany the police and inspect the two clinics operated by Reproductive Health Services. The purpose of the inspection was to verify if there was any abortifacient equipment. He gave witness in court that the two facilities had legal equipment normally found in a gynecologist’s clinic and he would be surprised if he did not find it as he uses the same equipment for his work. The police forensic department was asked to look for DNA on the equipment from the clinic. DNA was taken from any instruments or equipment with blood on them — even the couches and lab coats were confiscated. The results from the government chemist found that there was no DNA linkage between the fetuses found on the road and any blood specimens from the clinic. The doctor also found that the clinic was duly registered and all staff had proper and up-to-date licenses.

The case was eventually ruled as improper [Editor's note: They were acquitted of all charges]. With that ruling, the attorney general decided not to pursue prosecution due to lack of evidence.

Was it horrible being in prison for a year?

Yes, it was horrible, but it was worth the sacrifice. I was held at the Kamiti Maximum Prison, which is where the hard-core criminals are remanded. I was confined in a small cell for a whole year. I really felt persecuted, but as I said, it was worth the sacrifice.

Why do you say it was worth the sacrifice?

My arrest and imprisonment was in the media virtually every day. The publicity was an opening for people to realize the magnitude and consequences of unsafe abortion in Kenya; women were dying in great numbers. Before that, abortion was never spoken of in public. There are only about 250 OB/GYNs in Kenya; some districts have none. The media sensation from this case galvanized the Kenya Obstetrical and Gynaecological Society (KOGS), the National Nurses Association of Kenya, the Federation of Women Lawyers, human rights advocates, women’s rights organizations and many others to form an alliance of reproductive health rights advocates.

This alliance exists to date and is known as the Reproductive Health and Rights Alliance (RHRA). The RHRA is an advocacy platform to agitate for the reduction of maternal mortality and morbidity due to unsafe abortion. This alliance also offers technical support to abortion service providers through Reproductive Health Network (RHN). The public became aware of abortion and the toll of unsafe abortion. The window was open to the public to realize the terrible toll of unsafe abortion in Kenya.

This debate extended to the drafting of a new Constitution in 2010. The Constitution says that “every person has the right to the highest attainable standard of health, which includes the right to health care services, including reproductive health care.”

My arrest, imprisonment and [the resulting] publicity generated a public awareness that led to a transformation in the understanding that safe abortion is essential to preventing maternal morbidity and mortality.

Is there any further action in your own case?

Yes, I have since sued the government for malicious prosecution and subsequent confinement for one year in remand prison. The case has been in court for the last six years without yet being assigned a hearing.

What does the expansive definition of health in the new constitution mean in terms of when an abortion is considered legal?

Abortion is legal if the pregnancy endangers the life of the woman; as an emergency treatment; or when it endangers health, with health defined broadly: physical, social and mental. If in the opinion of a trained health professional an abortion is provided in good faith (in other words, where the pregnancy jeopardizes the woman’s physical, social or mental health), it is legal. [Editor's note: Under the new law, a woman can make her abortion decision with one health-care provider; others are not required to be involved or sign off on the decision.]

What categories of health-care providers can perform legal abortion?

Physicians, nurses, midwives and clinical officers [who have completed training to perform abortion services] can now perform legal abortions.

What are the next steps in transforming the policies to establish safe, legal abortion in Kenya?

Ipas and other organizations took the lead in writing a document called, “Standards and guidelines for reducing morbidity and mortality from unsafe abortion.” The title is taken from a similar document from Zimbabwe and is brilliant. Kenya, like other countries, wants to achieve the Millennium Development Goal of 75-percent reduction in maternal mortality; this can’t be achieved if safe abortion isn’t available.

The other milestone on transformation is the revision of codes of ethics and scope of practice for all the professional associations in Kenya. These have been done and are waiting to be launched.

This transformation to legal abortion access in Kenya is a testament to very brave, inspired people dedicated to the common good who have sacrificed a lot. How have all the changes we’ve discussed affected providers of safe abortion and women?

Providers are now aware of the enhanced protections that have been offered by the constitution. This in turn has increased access to safe abortion services and thereby enabled women to realize their reproductive health rights. In addition, incidences of provider harassment are now on the decrease.

 

Forced Pregnancy Testing: Blatant Discrimination and a Gross Violation of Human Rights

10:38 am in Uncategorized by RH Reality Check

Written by Onyema Afulukwe for RH Reality Check. This diary is cross-posted; commenters wishing to engage directly with the author should do so at the original post.

Earlier this month, news spread of a Louisiana charter school’s policy that would have allowed faculty to force any student suspected of being pregnant to take a pregnancy test — and, if the test came back positive, to force her to go on home study.

Forced pregnancy testing in schools is a gross violation of young women’s fundamental human rights. Through legal advocacy, I have been working to get it recognized as such and outlawed — in Tanzania, Kenya, Uganda, in my home country of Nigeria, and in other countries in the African region where it occurs. It is a shock to see a practice I’ve come to associate with schools in the developing world being replicated in the United States.

I have seen the consequences firsthand, and they are devastating. In secondary school, the older sister of a classmate, who was a year ahead of us, was found to be pregnant and expelled by school administrators. We eventually learned that she was the victim of a rape which occurred in her home, but she was too terrified to tell anyone what had happened. As is the case with many victims of this injustice, no other schools would accept her. Her hopes for a better future were doomed.

In Tanzania, where nearly 44 percent of girls have either given birth or are pregnant by the age of 19, school administrators across the country force schoolgirls to undergo demeaning pregnancy tests often just before completing primary school — around the age of 11 — and with increasing, and random, frequency throughout secondary school. Some girls must strip to their underwear to reveal physical signs of pregnancy. Others are coerced into taking urine-based pregnancy tests. No one can refuse to be examined or tested.

The impact is staggering, long-lasting, and far-reaching. About 8,000 girls are expelled or drop out because of pregnancy in Tanzania every year. Too often families abandon their pregnant teen daughters, forcing them to live on the streets with their babies. Faced with the possibility of homelessness, some young women succumb to pressure from their families to seek financial support through early or arranged marriages. The impact of these violations to their rights to health, education, privacy, and freedom from discrimination ripples throughout young women’s lives. Many female leaders of human rights advocacy groups still remember, over twenty years later, how humiliating and disempowering it was to experience forced testing even though they did not turn out to be pregnant.

Government officials do next to nothing to improve the situation despite its epidemic proportions; nearly 60 percent of the country’s adolescents have sex before 18. And in a double standard that’s all too common in many places throughout the world, while young women are stigmatized and penalized for pregnancy, the men and boys involved are rarely identified and face few consequences for their role.

In the United States, the reaction to the news about the Louisiana charter school was swift. Under threat of a lawsuit by the ACLU, the school reversed course and amended its student pregnancy policy, which no longer includes the invasive forced pregnancy testing it initially announced. The revised policy now assures female students the opportunity to continue schooling on campus throughout pregnancy and the option for homeschooling. This is a just and appropriate result.

Nevertheless, the emergence of this idea in an American school should trouble anyone concerned with the protection of our fundamental constitutional and human rights. And it should serve as a reminder of the importance of guarding vigilantly against violations of these rights not just in the developing world, but also — sadly, it seems — in the U.S.

Underreported and Unchecked: Sexual Violence Against Somali Refugee Women

8:32 am in Uncategorized by RH Reality Check

Written by Yifat Susskind for RH Reality Check. This diary is cross-posted; commenters wishing to engage directly with the author should do so at the original post.

Amal* left her village in Somalia when she realized that there was nothing left there for her. There was no food and no water. So she gathered her emaciated children and began the long trek to the refugee camps in northeastern Kenya. She thought that being forced to leave her home would be the worst thing to ever happen to her.

That was until she was attacked and raped by bandits on the way.

I recently returned from Kenya, where Somali women and families are seeking refuge by the thousands. I met with Hubbie Hussein Al-Haji of MADRE’s sister organization, Womankind Kenya, a grassroots women’s organization of Somali pastoralists. We talked about the most urgent needs for famine refugees—for food and water—and about how MADRE and Womankind Kenya can work together to provide for them.

And Hubbie told me about Amal and other women like her, who are arriving in northeastern Kenya traumatized not only from famine and displacement—but also from being raped along the trek.

Sexual Violence Rising in Famine-Struck East Africa

Women and girls seeking refuge at displacement camps must walk for days, along the long and dangerous routes to the Somalia-Kenya border. Bandits and Al-Shabaab militia patrol much of southern Somalia and have infiltrated deep into Kenya, often attacking women and their families to steal the few possessions they have. In Amal’s case, they took the only piece of gold jewelry she had ever owned. She had been hoping to trade it for food.

In these attacks, women have been raped. Even once they arrive at the displacement camps in Kenya, they are not safe. They need food and water, but there is not enough to go around. Many are turned away for lack of resources, relegated to the outskirts of the camps. There, local communities are struggling, not only to sustain themselves through drought and famine, but to offer aid to even harder hit famine refugees from Somalia. The women of Womankind Kenya come from these very communities and have long been mobilizing to confront this famine.

Even as refugees fight to survive, the threat of sexual violence persists. Women and girls are especially vulnerable when they venture out in search of firewood for cooking. As more refugees pour into the area, women must walk farther to find wood, putting them at greater risk of rape. In the area of Dadaab, now the biggest refugee camp in the world, violence against women and girls has quadrupled in the past six months.

Grassroots organizations like Womankind Kenya are a lifeline for rape survivors, especially those who have been turned away from the camps. These women are isolated and vulnerable, cut off from the communities of support they might once have had. Womankind Kenya can do more than meet their pressing needs for food and water. They can speak to women in their own language, breaking through their isolation to offer them care and a new source of support to lean on.

Looking Forward

We’ve seen this surge in sexual violence after disaster many times before. We saw it after the 2004 Indian Ocean tsunami, after the massive flooding of 2005’s Hurricane Katrina and after the catastrophic 2010 earthquake in Haiti. In each of these cases and many more, major disasters uproot communities and leave women and girls vulnerable to violence, including rape and sexual assault. In the chaos and loss of social cohesion that routinely follow disaster, women and girls in places as far afield as Somalia, Nicaragua or the United States are rendered more vulnerable to sexual attack.

To combat this rise in sexual violence, MADRE partners with local women’s organizations around the world that know well the gender-specific threats women and girls face after conflict and disaster – organizations like Womankind Kenya.

Now, Hubbie explained to me, Womankind Kenya is working to fill the gap in access to counseling services and medical care for rape survivors. MADRE is working with them to set up a mobile clinic to bring essential services to refugee women and their families. They will collaborate with local doctors and nurses, who they have worked with before, to reach out to women who need care. They will help women overcome fear of stigma by offering counseling and medical services that respect women’s privacy, and they will help women find their path to recovery.

When the women of Womankind Kenya reached out to Amal, she had all but given up hope. She had just arrived and was living at the edge of a camp. She had nothing, after having been robbed by her attackers. Womankind Kenya gave her emergency food and water, and what’s more, they listened to her story. It was only a first step but an essential one—for Amal and all of the refugee women and girls traumatized by rape.

*Not her real name

What Does US Policy Have to Do With Child Brides and Drought in Kenya?

10:34 am in Uncategorized by RH Reality Check

"Drought in Africa"

"Drought in Africa" by United Nations Photo on flickr

Written by Editor-in-Chief Jodi Jacobson for RH Reality Check. This diary is cross-posted; commenters wishing to engage directly with the author should do so at the original post.

There’s a saying that if you are not part of the solution, then you are part of the problem. When it comes to news that Kenyan families, facing serious drought conditions and unable to feed their families, are now selling their young daughters off to buy food, the United States is a part of the problem.

A big part.

Why?

As we reported two weeks back, the GOP and Tea Party majorities in the United States House of Representative are hell-bent on re-imposing the Global Gag Rule on U.S. international family planning assistance in a back and forth on policy that rivals Wimbledon.  And, as we reported in December 2010, House Republicans banded together to kill the International Child Marriage Prevention Act for no apparent reason other than to be ornery and adhere to a baseless ideology. The act would have required the U.S. government to develop an integrated, strategic approach to combating child marriage by promoting the educational, health, economic, social, and legal empowerment of women and girls, using existing resources. As in revenue-neutral, one of the terms du-jour.

To top all of this off, Republican Congressmen Chris Smith (NJ), Joe Pitts (PA), and Mike Pence (IN) succeeded during the Bush Administration in forbidding the integration of family planning information and supplies into HIV and AIDS programs, though unprotected sex is the leading cause of HIV transmission and of course the cause of unintended pregnancy. This of course undermined cost savings in addressing the related problems of HIV infection and unintended pregnancy and also denied HIV-positive women in particular the right to decide whether or not to have another child. The United States Conference of Catholic Bishops was particularly incensed at the idea these women would have such power and so lobbied very hard against integration. Read the rest of this entry →