by Sara Malakoff, Senior Program Associate, EngenderHealth
Female sterilization is the world’s most popular contraceptive method with more than 220 million users. Sterilization is convenient for women who desire to limit childbearing, as it requires no further visits to a health care provider. In addition, it does not have the side effects that contribute to the discontinuation of user dependent methods, such as hormonal contraception. However, access to both male and female sterilization varies significantly geographically, is limited in many parts of the world (particularly in rural areas), and has not increased at a pace comparable to that of the unmet need to limit childbearing.
In an attempt to address issues of full contraceptive choice and to ensure the availability of and access to a wide range of contraceptives, including permanent methods, Marie Stopes International (MSI) and EngenderHealth under the auspices of the Support for International Family Planning Organizations (SIFPO) project funded by USAID, convened a two-day technical symposium in Nairobi in March 2014 entitled Provision of Permanent Methods of Contraception in Low-Resource Settings. A dynamic group of over 40 participants from 27 organizations and 13 countries attended the event.
Guest post by Christina Wegs, Senior Advisor for Global Policy and Advocacy, CARE
December 10th was International Human Rights Day. This day commemorates the adoption of the Universal Declaration of Human Rights (UDHR) by the UN General Assembly in 1948, which affirmed the rights of all people, everywhere and all the time. The Declaration, as well as similar international treaties and agreements, confirm the centrality and importance of protecting and fulfilling sexual and reproductive rights (SRR). Embraced within the concept of SRR is the right to reproductive self-determination; the right to sexual and reproductive health (SRH) information, education, and services; the right to the highest attainable standard of health; and the right to equality and non-discrimination.
Despite international recognition of the importance of SRR, sixty years on and twenty years after the International Conference on Population and Development, women and girls in every part of the world continue to face considerable barriers to realizing their SRR. In many places, unmarried women and adolescents are denied access to reproductive health information and services, many women are not able to exercise full, free, and informed contraceptive choice, and women continue to die from preventable complications of pregnancy and childbirth. Pervasive gender inequality limits women’s decision-making autonomy and undermines their health and well-being throughout their lives. Finally, many women—especially poor and socially marginalized women—continue to experience systemic discrimination in health care, which not only results in poor quality of care and poor health outcomes, but also acts as a powerful disincentive to women seeking care.
In global health, nobody has an easy job, but ensuring voluntary and safe permanent contraception is among the toughest. Everything has to go right so that nothing goes wrong.
The latest disturbing news coming from Chhattisgarh, India, reminds us that despite being 20 years post-ICPD, we global health professionals have more to do to ensure reproductive rights, choice, and quality of care. And as the story goes—as it has too many times before—the devastating consequences are borne by mostly poor, rural women. It’s unconscionable.
Although the Chhattisgarh situation is under investigation by the Government of India, we know that quality of care was compromised at all levels. This includes the conditions under which the surgical sterilizations were performed, the high number of surgeries in a given period, the questionable quality of the medications, the implicit targets set by local authorities, and financial incentives. In many ways, there isn’t a simple answer to what happened–there were a series of systemic, programmatic and clinical failures. Many organizations, including EngenderHealth, have called for a greater need to ensure and protect human rights, reproductive rights and clients’ rights; and to address informed and voluntary decision making, counseling, client safety and service quality.
But how does this translate into action? What must go right so that nothing goes wrong?
EngenderHealth’s commitment to getting everything right, beginning with our work in voluntary permanent methods decades ago, has led to the development of standards used throughout the field for informed consent, clinical safety, infection prevention, and other aspects of quality service delivery. These have also been applied to broader family planning and reproductive health issues. What we’ve learned is that investments must take place at all levels – beginning with a fundamental recognition that individuals have a basic right to full and appropriate information about their reproductive health choices and that they are able to make decisions without coercion, pressure, or inducements. For EngenderHealth, it’s about achieving a vision of client-centered care and all that is meant by this term.
For example, in India it would mean expanding the contraceptive method mix in the public sector, ensuring quality, and working to advocate for a focus to be on client’s choices rather than achieving targets. Right now, it’s mostly sterilization services, intrauterine devices (IUDs), condoms and pills—a situation which limits choice for women and others, including unmarried adolescents. We also see a greater need for training so that service providers are equipped with skills to provide voluntary, safe and quality services and can monitor quality, rights and choice for continuous quality improvement. These are examples of the kinds of concrete actions that must be undertaken as part of a broader comprehensive strategy rooted in a rights-based approach.
The incident in Chhattisgarh is a sobering reminder of what can happen when family planning services are not designed, implemented, or monitored in a way that protects and fulfills individual's human rights. We urge the Ministry of Health and state governments to take decisive action to develop practical approaches for infusing a rights-based approach, with quality of care as one of the top priorities and with women’s needs, desires, and preferences at the center. To do otherwise would simply maintain the status quo.
EngenderHealth and its partners have developed two new publications to assist diverse audiences, including donors, policymakers, program planners and managers, service providers, rights advocates, and community members, in their efforts to achieve rights-based family planning programs.
The first publication is the Voluntary Rights-based Family Planning Conceptual Framework User’s Guide, a practical resource to help stakeholders design, implement, and monitor family planning programs that respect, protect, and fulfill human rights. Coauthored with the Futures Group, with support from the Bill & Melinda Gates Foundation, the guide is a companion to the recent publication of Voluntary Family Planning Programs that Respect, Protect, and Fulfill Human Rights: A Conceptual Framework, which took long-standing family planning concepts, such as quality of care, voluntarism, and service access and linked them with human rights principles, such as empowerment, equity, nondiscrimination, and accountability. The Framework provides a holistic vision of what a rights-based family planning program looks like; the User’s Guide provides a pathway to applying the framework in actual practice.
EngenderHealth also developed Checkpoints for Choice: An Orientation and Resource Package, which takes a closer look at the concept of voluntarism—one component of a rights-based approach—and helps stakeholders understand the clients’ experience and their ability to make full, free, and informed choices about family planning.The tool, developed with support from the William and Flora Hewlett Foundation and the United States Agency for International Development, consists of a detailed plan with all support materials for a one-day workshop to enable family planning program planners and managers to strengthen the focus of family planning programs on clients’ ability to make full, free, and informed contraceptive choices in the context of a rights-based program. In addition to the workshop guidance and materials, the package includes links to recommended references, tools, and additional reading.
Worldwide, women choose injectable contraceptives because they are safe, reliable, and discreet. In many rural or remote areas, however, travelling to a clinic to receive an injection is costly and burdensome. PATH, an international nonprofit health organization, is collaborating with global partners to address this challenge. We began with a basic question: What would it take to deliver more injectable options to women, particularly outside the clinic setting?
One answer is Sayana® Press: a small, easy-to-use injectable contraceptive that has the potential to increase access and choice for millions of women worldwide.
“You’ve done remarkably well!” Those were the admiring words of an incredulous high-level United Nations (UN) official, when a colleague and I met him a few weeks ago to discuss the outcome of the Open Working Group (OWG) of the General Assembly on the Sustainable Development Goals (SDGs). “We,” of course, are the women’s groups (organized as the Women’s Major Group) who've fought long and hard to ensure that a standalone goal on gender equality would feature in the SDGs proposed by the OWG. The inclusion of gender equity was not a given, but it was achieved.
We had also pressed governments to ensure that sexual and reproductive health and rights (SRHR) would be included as targets under both the gender goal (SDG 5) and the goal on health (SDG 3). We came away with a significant, if partial result: Under SDG 3, governments agreed, by 2030, to “ensure universal access to sexual and reproductive health care services, including for family planning, information and education, and the integration of reproductive health into national strategies and programmes” (target 3.7). Under SDG 5, they also agreed to “ensure universal access to sexual and reproductive health and reproductive rights as agreed in accordance with the Programme of Action of the ICPD and the Beijing Platform for Action and the outcome documents of their review conferences” (target 5.6).
Governments also agreed to “eliminate all harmful practices, such as child, early and forced marriage and female genital mutilations” (target 5.3). Other important targets included to eliminate all forms of violence against all women and girls (target 5.2), reduce the global maternal mortality ratio to less than 70 per 100,000 live births (3.1), end the epidemics of AIDS, tuberculosis, and malaria (3.3) and achieve universal health coverage, including financial risk protection, access to quality essential health care services, and access to safe, effective, quality, and affordable essential medicines and vaccines (3.8). Compared to the Millennium Development Goals, the proposed SDGs represent significant progress, addressing critical areas for action that, if implemented, will transform the lives of women and girls globally. They also put the lie to claims that “we could never get today the agreements we obtained in the 1990s.” We have in fact gone beyond them.
What now? The General Assembly will begin its final negotiations on the final post-2015 development agenda early next year, for adoption in September 2015. Governments from the global South have clearly indicated that they expect the outcome of the OWG to be the basis for negotiation, and would not tolerate attempts by the Secretary General’s staff to “streamline” its 17 goals and 169 targets. That is good news for SRHR, because these targets were the most thoroughly debated and negotiated in the OWG. What emerged on SRHR from the OWG certainly represents global consensus, despite objections from a handful of opponents led by the Holy See and Saudi Arabia.
The OWG document can and should be improved upon. Human rights, the rule of law, and access to justice were not sufficiently established as key aspects of development. As noted by several governments last month at the UN General Assembly’s first ever panel discussion on child marriage, preventing child, early, and forced marriage should be its own target since it has multiple, far-reaching causes and consequences. “Sexual rights” (i.e., the right of everyone to have control over matters related to their sexuality, free of coercion, discrimination, and violence) were omitted from the SDGs, despite having been agreed to by governments at Rio+20 and recent ICPD Beyond 2014 reviews in Africa, Asia-Pacific, and Latin America and the Caribbean. Non-discrimination on the basis of sexual orientation and gender identity, which the UN Human Rights Council has just again denounced, should be included. Finally, adolescents and their right to sexual and reproductive health services and information, including comprehensive sexuality education, must be addressed if the post-2015 agenda is to be relevant for the 2.4 billion children under the age of 19 alive today.
The freedom to determine what happens to our own bodies and to make decisions about sexuality, relationships, and childbearing are fundamental facets of our lives. By investing in and promoting these rights, governments can unleash the power of women and girls and transform societies.
Last month, the global community celebrated the 20th anniversary of the International Conference on Population and Development (ICPD). The ICPD, which took place in Cairo in 1994, led to an historic agreement by 179 governments to place women—and importantly, their reproductive health—at the center of the sustainable development agenda. Five years later, while at the State Department, I served as the U.S. government’s “officer in charge” for the five-year review of the ICPD, where we exulted when the global community agreed to advance the ICPD agenda through promoting access to safe abortion, comprehensive sexuality education, and youth-friendly reproductive health services, among other critical areas.
Blog post by Jan Kumar, EngenderHealth/RESPOND Project
The planets have aligned in Uganda over the past few weeks for a significant shift in the country’s national family planning (FP) program that sets it on a new and ground-breaking course. From July 28-30, 2014, the Ugandan Ministry of Health (MOH)—with support from the United Nations Population Fund (UNFPA)—hosted an event titled “Accelerating social and economic transformation through universal access to voluntary family planning.” President Museveni used this opportunity to accelerate the government’s commitment to FP2020 and to voice his endorsement for FP as a means to improve maternal health, reduce poverty, and support social and economic development. The meeting paved the way for the promotion of equitable access to a wide range of quality FP services that ensure full, free, and informed choice, as well as the protection and fulfillment of human rights for all Ugandan women and couples who wish to space or limit their childbearing.
Family planning (FP) programs in developing countries have been experiencing a phenomenon that I like to call “the leaking bucket.” Let’s say that you place a bucket under an open tap and watch the water level rise, until you discover a hole in the bottom of the bucket. Water is now leaking out of the bucket. Filling the bucket will be easier once the hole is plugged. In the same way, meeting women’s desire to reduce unwanted fertility will become easier once FP programs pay more attention to contraceptive discontinuation.
Like all women and men, people living with or at risk of acquiring HIV have the right to determine the number and timing of their children and to safely achieve their reproductive intentions. Yet many women and couples affected by HIV lack access to family planning (FP) services and experience disproportionately high rates of unintended pregnancy and abortion. Why is this so? One major challenge is that myths, misinformation, and stigma with regard to the sexual and reproductive health (SRH) rights of people affected by HIV continue to persist among healthcare workers.
Research has shown that healthcare providers often have poor knowledge, attitudes, and behavior with regard to providing contraception to clients affected by HIV. For example, they often (incorrectly) emphasize condoms as the sole FP option appropriate for these women and couples. Moreover, most do not routinely discuss the importance of dual method use, offer other more reliable contraceptive method options, or provide emergency contraception.
On July 17, Katja Iversen, CEO of Women Deliver, published “Working Hard to Get the World We Want: Sexual and Reproductive Health and Rights After 2015” on The Huffington Post’s Global Motherhood blog. In this post, Iversen reports on the work of the Open Working Group (OWG) for Sustainable Development Goals, which is comprised of representatives from 70 countries and tasked with the creation of a new global framework for development that they are set to present to the United Nations Secretary-General Ban Ki-moon by the end of July. The influence of this report on the future of international development, sustainability, and human rights cannot be overstated.
The goals and targets it proposes—and the issues explicitly addressed—will be of utmost importance in the shaping of the post-2015 development agenda. Due to conservative push-back, Iversen decries, the current report language fails to include sexual and reproductive health and rights (SRHR), as well as the health of young people despite the fact that “the majority of governments have identified [SRHR] as a priority to get the world on a sustainable path.”
The blog post discusses the vital role that voluntary family planning and ensuring rights and contraceptive choices for women and girls play in ensuring equal opportunity, economic growth, and the development and maintenance of healthy populations. Iversen urges readers to take action and suggests ways to become involved in supporting the push for inclusion of SRHR in the forthcoming global development framework. Read this important post and join EngenderHealth, Women Deliver, and other organizations and individuals in the effort to make SRHR a priority in the post-2015 global development agenda and a reality for all.