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You Can’t Have it Both Ways: The Interpretation of Catholic Health Policy and the Consequences for Pregnant Women

12:46 pm in Uncategorized by RH Reality Check

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

Republished with permission from Reproductive Health Matters.

“There is only one way to be sure a woman’s life is at risk, that is, after she dies.” — Christian Fiala, 2012

 

A view of Galway Hospital and parking lot

Savita Halappanavar died at Galway University Hospital.

In 1987, the year the first Safe Motherhood Initiative was launched by the World Health Organization (WHO), there were more than half a million maternal deaths annually. The women who were dying were often anonymous and their deaths never recorded or studied. They were mainly from poor and often rural backgrounds in developing countries, such as India. A study in India published in 1999 comparing 100 maternal deaths in a Rajasthan hospital in 1983-85 to 100 in 1994-96 found that: “Most of the women who died in hospital in 1994-96 would have died at home in the earlier decade.”1 What had changed was that they had reached a hospital and were therefore no longer anonymous, but they were still overwhelmingly women living in poverty with little or no access to skilled pregnancy and delivery care. 

Contrast this with the death of Savita Halappanavar on 28 October 2012, a dentist from a privileged background in India, who miscarried 17 weeks into a very wanted pregnancy and died in the maternity ward of a hospital in Ireland, a country with a very low maternal death ratio.2 Savita’s death was anything but anonymous; her name and photograph circled the globe within days of her death and sparked street demonstrations and protests, not only across Ireland but also in many other parts of Europe and in India. Six weeks later, articles and blogs about her death continued to be published in many countries, demands by her husband for a maternal death audit were headline news, and the Irish government has been forced to consider the effects of her death for the law, health policy and the Constitution of Ireland. 

Savita’s death became iconic for a number of reasons. First, preventing maternal deaths has been a global priority since 1987 when the first WHO Safe Motherhood Initiative was launched. Since 2000, reducing maternal deaths by 75 percent by 2014 has been the main target of Millennium Development Goal No.5, and since 2010 it has been one of five main goals of the UN Secretary-General Ban Ki-Moon’s Global Strategy on Women’s and Children’s Health. Hence, maternal deaths have started to be a news item globally, with journals like Reproductive Health Matters carrying studies and the media in many countries where deaths remain frequent, reporting successes and failures to reduce deaths, and individual stories regularly.

Secondly, holding governments accountable for their failure to provide the required services, both antenatal and delivery care and emergency obstetric care, to prevent avoidable maternal deaths has become the subject of public protests by women’s rights advocates, of court cases, including in India, and of hearings by human rights bodies, particularly CEDAW, examining individual cases and making policy recommendations to governments.3

What was different about Savita’s death, however, was the fact that it was also about whether and when to terminate a pregnancy when it is not viable and the woman’s health and life are at risk, and how that intersected in Savita’s case with individual health professionals’ interpretation of Catholic health policy and the law on abortion in Ireland. 

As a committee of the Irish Parliament considers proposals to offer limited legal abortion in Ireland, this paper explores how these issues came together around Savita’s death, the interpretation of Catholic health policy and the consequences for pregnant women.

Preventing maternal deaths as global policy

Maternal deaths, especially in countries where they remain frequent, are getting more and more media coverage. The Millennium Development Goals have made countries with continuing high maternal mortality ratios4 conscious of their shortcomings, and civil society organizations are beginning to pursue justice and even compensation in individual cases. 

In India, for example, a petition for legal redress was filed in the Delhi High Court in the case of Shanti Devi, who died in childbirth in January 2010 after two high-risk pregnancies in which she received delayed and insufficient care. With the first of these two pregnancies, she fell down the stairs and afterwards could no longer feel the baby moving. Induction of the pregnancy was delayed until she required intensive care which, when she finally received it, was inadequate. With her health still very precarious, she became pregnant again six months later, went into labor prematurely at seven months, delivered the baby at home without a skilled birth attendant or any medical assistance, and within an hour after delivery, began hemorrhaging and died. This case ensured that the Court took into account not just the individual death but also the constitutional and human rights obligations of the central government of India.5

Some communities where women are at high risk because of the lack of routine and emergency obstetric care are also beginning to protest against maternal deaths. One such event took place in Uganda where, in May 2011, hundreds of concerned citizens and health professionals stormed the Constitutional Court in Kampala, Uganda, protesting the deaths of women in childbirth, in support of a coalition of activists who took out a landmark lawsuit against the government over two women who bled to death giving birth unattended in hospital.6

Another example from India comes from Barwani district, Madhya Pradesh, India, where there were local protests against 27 maternal deaths in the period from April to November 2010. In January 2011, an NGO fact-finding team found an absence of antenatal care despite high levels of anemia, absence of skilled birth attendants, failure to carry out emergency obstetric care in obvious cases of need, and referrals that never resulted in treatment.7

Events like these are making the governments concerned highly sensitive to criticism. As an upper middle-class woman, Savita Halappanavar would have been highly unlikely to die in India from the appalling treatment experienced by Shanti Devi or the tribal women in Barwani. Yet, ironically, the Indian government was among the first to criticism those in Ireland who failed to prevent Savita from dying. For example, India’s ambassador to Ireland said that Mrs Halappanavar may be alive if she had been treated in India.

Emergency obstetric care, termination of non-viable pregnancies and Savita’s death

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No Clapping Matter: Antibiotic-Resistant Gonorrhea Is On the Way and We Are Not Prepared

12:48 pm in Uncategorized by RH Reality Check

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

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When I was a peer sexuality educator at UMASS-Amherst back in the early 1990s we used to joke about the fact that the only gynecologist on staff at the health center was named Dr. Daniel Clap. At the time it seemed hilarious that the man charged with prescribing our pills and diagnosing our sexually transmitted diseases (STDs) seemed to be named after one of the most common STDs. None of us knew why gonorrhea was called the clap (more on that later). In truth, apart from making the joke about the gynecologist’s name, none of us thought much about this bacterial infection that had been reduced a nuisance by the advent of antibiotics long before we were born. Sure, we stressed how condoms can prevent gonorrhea and how important it was to get tested for it because it often has no symptoms but in the workshops we led we paid far more attention to the “4-H club” because these diseases—HPV, HIV, Hepatitis B, and Herpes—were ones you might have to live with for the rest of your life.

We were not alone in our complacency around gonorrhea. The disease is easily prevented by condoms, easily tested for in STD clinics, and easily cured. HIV got attention for being potentially life threatening. HPV got attention for being so widespread and leading to cervical cancer. Gonorrhea was annoying but not much of a menace. Deborah Arrindell, Vice President, Health Policy for the American Social Health Association (ASHA), explained it this way:

“We think of gonorrhea as a funny infection—the clap—that doesn’t kill anybody.  But the consequences of untreated gonorrhea are quite serious; infertility, increased risk of HIV, and a big impact on our national wallet…nothing to clap about there.”

Today, many in the public health community will admit that we collectively took our eyes off the ball because Neisseria gonorrhoeae is a very clever bug that has developed the ability to resist nearly all of the antibiotics that have been thrown in its path. It has steadily developed resistance to entire classes of antibiotics—as early as the 1940s it was resistant to sulfanilamides, by the 1980s penicillins and tetracyclines no longer worked, and in 2007 the CDC stopped recommending the use of fluoroquinolones (the class of drugs that includes Cipro, which we may all remember as the thing to stockpile in case of an anthrax attack). Today, the only class of antibiotics that remains effective are cephalosporins, but its susceptibility to these drugs is declining rapidly in the United States and other countries have already seen cephalosporin-resistant cases.

In February the Centers for Disease Control and Prevention (CDC) sounded the alarm about this growing threat and suggested that we need to change the way we screen for and treat gonorrhea in this country in order to respond to this wily germ. Last week, the World Health Organization (WHO) released a statement on this issue and, more importantly, a global action plan for stemming the spread of drug-resistant gonorrhea. As the resistant cases emerge, it is a good time to look at how we got here and what we can do to ensure that gonorrhea does not become a major public health threat.

Cephalosporin-Resistant Gonorrhea is Coming

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