The Dire State of Reproductive Rights Worldwide

Each day, an estimated 830 women die of preventable causes related to pregnancy and childbirth. Disproportionately affected are adolescent girls and women living in rural and impoverished areas. Providing women with universal access to family planning is one important and cost-effective way to help reduce maternal deaths. Doing so would decrease maternal deaths by a third. In developing countries, investing in family planning would lead to 2.4 million fewer unsafe abortions (one of the top causes of maternal deaths worldwide according to the WHO) and 5600 fewer maternal deaths related to unintended pregnancies. In addition, it would decrease infant mortality by anywhere from 10 to 20%.

Availability of family planning services has clear benefits in protecting the health of women and children, but it also offers so much more than that. When women can plan the timing and spacing of their pregnancies, women are more likely to attend and finish school; achieve higher levels of education; gain access to better job opportunities; contribute positively to her community; and improves the chances that she will invest in her children’s health, education, and well-being. In short, when women do better, societies do better.

This is all at grave risk now. As part of Trump’s first executive order, he reinstated the global gag rule which when implemented, states that the US can withhold family planning foreign assistance to any foreign non-governmental organization that so little as provides information on abortions, and that’s even if the organization receives funding from other sources. It’s important to note that the US already prohibits any foreign assistance from funding abortions under the Helms Amendment, which has been in place since 1973.

The re-enactment of the global gag rule comes as no surprise, as historically it has been re-enacted by every Republican president since Reagan then overturned by every Democratic president. Ironically although it has been argued that the gag role was put into place to decrease the number of abortions, a Stanford study found that abortions actually increased in years that the gag rule was in effect. It has also been shown that cutting off family planning funding to these organizations severely limits and in some cases, completely ceases, their ability to provide contraceptives and reproductive health services, thus increasing unintended pregnancies and unsafe abortions and further worsening maternal health outcomes.

The newest reinstatement of this rule however, extends far beyond the scope of the original rule and withholds all US global health assistance, not just family planning foreign assistance, to organizations that perform or provide any counseling, referrals, information, or advocacy on abortions. This revision of the global gag rule will not only hurt the millions of women in some of the poorest areas of the world who heavily rely on US-funded organizations which provide family planning services like contraception, but now impacts vulnerable men, women, and children alike. That’s because many of these organizations provide so much more than reproductive health services. Many of these organizations are hospitals and clinics, which in addition to reproductive health services, provide the full spectrum of medical care including life-saving childhood vaccinations, treatment for survivors of gender-based violence, HIV prevention and care, prenatal and postnatal care, and play a vital role in preventing the spread of infectious diseases like Zika and Ebola.

This is an unprecedented setback for the global health community and a huge threat to the advances that we have made in the fight against emerging infectious diseases, HIV/AIDS, and maternal and child mortality to name a few. We cannot let the progress we’ve worked so hard for be eradicated. Let us always remember that progress is something we must work for everyday, a call to action that is becoming more imperative in the precarious times ahead of us.

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US support for family planning foreign assistance currently stands at $575 million to 40 countries. With the institution of this new rule, $9 billion of global health assistance to 60 countries is currently at stake.

Here are a few ways to get involved:

Read APHA’s statement opposing reinstatement of the global gag rule.

 

Female sterilization not an answer to global contraception

The last week of September marks two days dedicated to improving reproductive health: World Contraception Day  (September 26) and Global Day of Action for Access to Safe and Legal Abortions  (September 28).  Both days are committed to improving the reproductive health and choices of women worldwide. With the vision of making every pregnancy a wanted pregnancy, World Contraception Day aims to help the estimated 225 million women in developing countries who have an unmet need for contraception.

Reports such as the UN’s 2015 Trends in Contraceptive Use Worldwide include somewhat promising data, such as 64% of married or in-union women use a modern contraceptive method. This figure is lower in developing countries, including 17 countries in Africa where modern contraceptive use is below 20%.

Sterilization is the most widely used form of birth control, accounting for a third of modern contraceptive use. Sterilization is heavily weighted toward female sterilization, 18.9% versus 2.4% male sterilization globally.  In certain countries, the prevalence of female sterilization as modern contraception is much higher.  Female sterilization of sexually active women aged 15 to 49 is most prevalent in Latin America.  The Dominican Republic leads the pack at 47%  followed closely by Colombia, Costa Rica, El Salvador, and Puerto Rico.  China (29%) and India (36%) are also front runners.

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Sterilization is a popular choice in the developed countries of Europe and North America, though male sterilization tends to be more prevalent than in the developing world. When practiced safely, sterilization offers many benefits because it is a one-time procedure with no follow-up or maintenance.  While sterilization might be the best choice for some individuals or couples, unsafe, involuntary, or otherwise coercive female sterilizations are altogether too common and an affront to human rights.

China’s “one child” policy  – perhaps one of the more infamous anecdotes in mandated family planning – has relied on sterilization to meet its goals.  In the heyday of the 1980s, neighbors became informants on so-called “out-of-plan” pregnancies.  Offending families were fined and possessions stolen, and local bureaucrats oversaw countless forced abortions and sterilization. 1983 alone saw over 20 million sterilizations. China’s Communist Party has recently relaxed its one-child policy  to allow each couple two children, but many in China, including activist Chen Guangcheng don’t see the difference as stated in this tweet:

This is nothing to be happy about. First the #CCP would kill any baby after one. Now they will kill any baby after two. #ChinaOneChildPolicy

Lesser known is an Uzbekistan policy that assigns gynecologists a sterilization quota of up to 4 per month.  In a report by the BBC, rural women who have had two or more children are the main target of this campaign.  It is estimated in 2011 alone that 70,000 Uzbek women were sterilized, some voluntarily and some involuntarily.  Unlike China’s policy to slow population growth, Uzbekistan’s goal is to manipulate its once abysmal infant mortality ratings.  Fewer infants means fewer infant deaths, and Uzbekistan’s infant mortality rate in 2012 is half of what it was in 1990.

India has received much attention for its sterilization camps.  The name alone conjures images of the Nazi eugenics movement.  In 1951, with Malthusian ideology in mind, an Indian demographer set out across rural India to complete a census.  His prediction – that India’s population would reach 520 million people by 1981 – was both incorrect (India’s population in 1981 was 683 million ) and the catalyst for a mass sterilization program.  This led to compulsory sterilization in 1976  that lasted for 21 months and effectively sterilized 12 million men and women, often rural, poor, and of low caste.  Employment, wages, and even running water were withheld from individuals and whole villages until 100% compliance was met.

Today, while technically voluntary, sterilization in India is incentivized. In the past, men were promised transistor radios in exchange for a vasectomy.   Male sterilization is now considered culturally unacceptable.  Women are the target of sterilization campaigns and can receive up to $23 US – a month’s income – to submit to a tubal ligation.

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Women undergo sterilization operations at the Cheria Bariarpur Primary Health Centre in the Begusarai District of Bihar. A few dozen women were sterilized in one day. Although India officially abandoned sterilization targets years ago, unofficial targets remain in place, according to people working on the ground. One Primary Health Centre doctor says the targets in themselves are not necessarily the problem, arguing instead that itÕs the lack of a good healthcare infrastructure in some places that makes it difficult to safely meet those targets. SARAH WEISER

Indian women arrive at sterilization camps by the jeep load.  In makeshift operating theaters –  with no electricity and running water – neither gloves nor equipment are changed between the five-minute operations.  Expired antibiotics given to some women are found laced with rat poison.  In 2014, Dr. R.J. Gupta, self-described as performing 300 tubal ligation in one day, was arrested after women he and an assistant sterilized either died or were hospitalized.  The current government regulation is that no one doctor should perform more than 30 sterilizations a day.  On the day in question, Gupta’s six-hour spree resulted in 83 tubal ligation.  It is believed that Gupta was trying to reach a government-set target of 220,000 sterilizations in one year.

On September 14th of this year, India’s Supreme Court ordered a close of all sterilization camps within three years.  That is an unsettling time span in which over a half a million more women could be sterilized and many more deaths and hospitalizations could occur.  Even after the dissolution of government-sanctioned sterilizations camps, women will continue to be subject to this dangerous procedure.

What are low cost, accessible, and humane forms of birth control for the developing world?  A promising alternative might be Sayana® Press, a lower-dose presentation of the three-month injectable contraceptive Depo-Provera® in the Uniject™ injection system.

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A village health worker counsels a client in family planning and administers Sayana Press. Phiona Nakabuye (left), village health worker trained by PATH’s Sayana Press pilot introduction program, with Carol Nabisere (right), age 18, who chose to receive Sayana Press after being counseled in the various forms of contraception, Kibyayi village, Mubende district.

Original trials of the injectable contraceptive were successful in Florida, New York, and Scotland, and the same seems to be holding true in Uganda.  Most women were able to self-administer the drug after just one training session and again at the next dose, three months later.  Designed for single use, Sayana® Press reduces reliance on needles and needle sharing  which is essential in the fight against HIV/AIDS and women only need to travel to a clinic once to get a year’s supply.

There is so much to consider when it comes to global family planning.  It would be remiss not to mention the impact that the HIV/AIDS epidemic has on sterilization rates in some regions of the world and you can read more here, here, and here.  Organizations such as USAID have been implicated  for funding so-called fertility reduction programs that include mass sterilization.  What can be done to ensure all women have access to contraception?

Which Top Family Planning Research Findings should be put into Practice? Vote!

Which are the most important family planning research findings that should be put into practice? Authors for an upcoming Population Reports issue on the topic invite you to vote for the top three findings from a list of seven. For example, WHO recommends that family planning clients receive up to a year’s supply of pills, or as many pill packs as feasible, at the first visit. Research finds that women who get a full year’s supply of pills are more likely to use the method effectively, without interruption. This practice is rare in many countries, however. Have a more urgent finding that should become a practice? Vote and then write a comment on INFO’s Blog.