Religion and governance: strange bedfellows #Vaw #womenrights


BMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.f3715 (Published 7 June 2013)

Cite this as: BMJ 2013;346:f3715
  1. Anita Jain, India editor, BMJ

Author Affiliations

  1. ajain@bmj.com

An unexpected turn of events saw a woman referred to as Beatriz get a life saving caesarean section, thanks to doctors in El Salvador who supported her cause, and a rousing international movement. She was earlier denied an abortion, it being criminalised in predominantly Catholic El Salvador, with the ensuing imprisonment of women and doctors (doi:10.1136/bmj.f3612). Timely intervention prevented Beatriz going the same way as Savita Halappanavar did a few months back in Ireland. Savita died after being denied an abortion on the grounds that “it [Ireland] is a Catholic country” (doi:10.1136/bmj.f2208). Her death and Beatriz’s struggle for life raise the question: Why does religion interfere?

A parallel conflict between religion and governance is taking place in the Philippines. At the Women Deliver conference I attended last week, it pained me to hear Filipino women with 16 and 22 children talk of how they were tired of having children, of having to provide for them under conditions of extreme poverty, and fearful of dying in the process of childbirth. Senator Pia Cayetano provided an inspirational narrative of having the reproductive health bill passed last year after five congresses and nearly 15 years. Recognised by President Aquino as a “matter of urgency,” the law marks a momentous achievement to make available free contraceptives, sex education, and comprehensive obstetric services (doi:10.1136/bmj.e8535). The struggle is not over however. With a largely Catholic, conservative, and patriarchal hierarchy, the constitutionality of this law has been challenged in the Supreme Court.

In a review of abortion policies worldwide, Sophie Arie reports a threat that countries may be headed towards being more restrictive (doi:10.1136/bmj.e8161). Closer to home, India may laud itself for a progressive abortion law but it continues to have one of the highest rates of unsafe abortions. Suchitra Dalvie, coordinator of the Asia Safe Abortion Partnership, shares grim statistics whereby, “every year about 11 million abortions take place [about 700 000 are reported] and around 20 000 women die due to abortion related complications.” Clearly the law has not translated into enabling physical, social, or financial access to these essential reproductive health services (doi:10.1136/bmj.f3159). Contrary to what may be expected, states are further imposing severe curbs on medical abortion pills (doi:10.1136/bmj.f1957). In the latest BMJ poll we look forward to hearing what you think of this.

Signifying a commitment to make comprehensive family planning services a reality globally, the London Summit on Family Planning (FP 2020) laid the ground for collaboration among donors and governments (doi:10.1136/bmj.e4160). At Women Deliver, Kavita Ramdas from the Ford Foundation emphasised, however, that “access to contraceptives” needs to be the message, and not just family planning. The importance of this is immediately evident in a similar conflict between the state and religion in Muslim dominated Indonesia where unmarried women are denied reproductive health services including contraception. Shereen El Feki, author of Sex and the Citadel, shared voices of young unmarried men and women from the Arab region who are “sexually active, but not sexually informed” as “marriage remains the only the only socially accepted context for sex—state-registered, family-approved, religiously-sanctioned.” The needs of this large and growing community of single men and women often tend to be neglected in the discourse on family planning.

Nozer Sheriar, secretary general of the Federation of Obstetric and Gynaecological Societies of India (FOGSI), shared that, with an estimated 21.6 million women worldwide experiencing an unsafe abortion each year and with about 70 000 deaths, it is a silent tsunami knocking door to door. As symbolised by Salvadoran doctors who stood strongly behind Beatriz so she would not die giving birth, there is a role for healthcare providers to support women’s choice on this reproductive right that society is so reluctant to give.

Notes

Cite this as: BMJ 2013;346:f3715

Footnotes

  • Follow Anita Jain on Twitter @ajain247

Needless hysterectomies on poor women rampant across India: Study #Vaw #womenrights


Malathy Iyer, TNN Feb 10, 2013, 01.12AM IST
(Oxfam said that unnecessary…)

MUMBAI: Is India witnessing a spurt in unnecessary hysterectomies? Data released by international charity organization Oxfam on February 6 says as much. The agency said that unnecessary hysterectomies were being performed in Indian private hospitals to economically exploit poor women as well as government-run insurance schemes.

A right to information ( RTI) request filed by one of Oxfam’s local NGOs in the Dausa district of Rajasthan showed that 258 of 285 women—65%—investigated over six months had undergone hysterectomies. Many of these women were under 30, with the youngest being 18 years old.

An editorial in the British Medical Journal quoted Oxfam’s global spokesperson Araddhya Mehtta as saying that the “trend is seen all over India but is particularly disturbing in Rajasthan, Bihar and Chattisgarh where doctors simply abuse their power of being a doctor”. In 2010, the Andhra Pradesh government tweaked its state-sponsored insurance scheme to disallow hysterectomies in private hospitals after surveys revealed that uteruses of a number of beneficiaries were removed merely to claim higher insurance amounts (the state insurance scheme is only available for the economically poor sections).

Dr Duru Shah, former president of FOGSI (Federation of Obstetric and Gynaecological Societies of India), said that modern medicines could fix 95% of woman’s menstrual problems without the need for surgery.

However, experts fear the trend of unnecessary hysterectomies possibly exists in urban centres such as Mumbai as well.

Indeed, an audit performed by insurance companies in Chennai in 2009 had shown that more than 500 women in the 25-35 age group had undergone hysterectomies. A Central government study in the wake of the Andhra Pradesh scam had said that women under 45 rarely needed hysterectomy.

A 2011 research paper in medical journal Reproductive Health Matters, conducted by SEWA Health Cooperative doctors in Ahmedabad, showed that insured women—both in urban and rural areas—had higher rates of hysterectomy. “Among insured women, 9.8% of rural women and 5.3% of urban women had had a hysterectomy, compared to 7.2% and 4.0%, respectively, of uninsured women,” said the study.

The OXFAM report, in fact, says that India should end its public-private partnership programmes (that allow poor women with government insurance plan to undergo a hysterectomy in private hospitals) until better regulation is in place.

Oxfam official Mehtta has been quoted as saying, “When women came with abdomen pain, doctors prescribed hysterectomy to women from poor economic backgrounds, telling them that it might be a cancer or a hole or a stone in the uterus without doing any thorough necessary investigations.”
Dr Duru Shah said that unnecessary hysterectomies affected the concerned woman’s health. “A young woman who has undergone hysterectomy may suffer early menopause (stoppage of periods) and the accompanying health problems of increased risk of cardiac diseases and fractures due to brittle bones,” she said.

Dr Rekha Daver who heads the gynaecology of J J Hospital, Byculla, said, “Generally speaking, there may be a marginal increase over the years. But this may only be because women from rural areas who travel to referral centres in cities don’t want to prolong their suffering.” She said it wasn’t feasible for these women to return to cities a second time for any treatment that may be required.

Incidentally, Maharashtra doesn’t allow hysterectomies in private hospitals under the insurance scheme launched last year for the economically weaker sections, called the Rajiv GandhiJeevandayee Arogya Scheme. “We have learnt from the Andhra Pradesh experience,” said Dr K Venkatesam, CEO of the arogya scheme.

However, not all agree that hysterectomies are on the rise. Gynecologist Dr Rakesh Sinha from Mumbai said, “It would be wrong to say there is an epidemic of hysterectomies in Mumbai or India. What has changed over the past few years is that we have facilities such as USG to make early and accurate diagnosis. Moreover, there are procedures available that allow women to go home within a day or two.”

 

Most pregnancy-related deaths occur in transit’


A map of the world showing country-level mater...

A map of the world showing country-level maternal mortality rates. (Photo credit: Wikipedia)

AARTI DHAR, The Hindu

Maternal Death Reviews reveals many facilities show mothers the door soon after delivery

According to a study conducted on pregnancy-related deaths, a large number of women die during transit to a health facility or returning home after a delivery. ‘Maternal Death Reviews — Implications for Quality of Care,’ (MDR) a review of maternal deaths done by the Federation of Obstetric and Gynaecological Societies of India (FOGSI) in Jhunjhunu and Sikar districts of Rajasthan between November 2010 and March 2012 has revealed that 90 per cent of these deaths had occurred during transit to a higher health centre.

The study, conducted on 819 deaths of a total of 1,065 probably maternal deaths reported in Madhya Pradesh between April 2011 and January 2012, suggests 132 women died on their way home or to a health facility. A similar analysis done in 69 health facilities in Karnataka has revealed that 20 per cent women die during transit.

Experts believe such deaths could possibly have increased because of an emphasis on institutional deliveries and a lack of corresponding clinical infrastructure — the Janani Suraksha Yojana gives women financial incentives for delivering at a health facility, but are often taken to the health facility as a mere formality and often asked to go home immediately after delivery because of lack of infrastructure to deal with the heavy patient load, which puts the life of the child and mother at huge risk.

This reality came across during a daylong conference to mark the Safe Motherhood Day last week, where participants from several States shared their experiences and progress on maternal death reviews.

The MDR was rolled out in 2010 under the Reproductive and Child Health programme as an important strategy to improve the quality of obstetric care and to reduce maternal mortality and morbidity.

It provides detailed information on various factors at the facility, district, community, regional and national levels that need to be addressed to reduce maternal deaths. Analysis of these deaths can identify the delays that contribute to maternal deaths at various levels and the information can be used to adopt measures to fill the gaps in service.

While haemorrhage, sepsis, abortion, obstructed labour and hypertensive disorders are the major medical causes of maternal deaths in the country, delay in initiating treatment, substandard care in hospital, lack of blood, equipment and drugs in hospitals coupled with lack of staff at health facility are other factors that often lead to the death of a young woman.

At the community level, absence of ante-natal check ups, delay in seeking care, referral, getting transport, mobilising funds and not reaching the appropriate facility in time are some other factors of maternal deaths, besides prevailing beliefs and customs that prevent women from going to a health facility at the appropriate time.

In a presentation on maternal death reviews in Madhya Pradesh, Apurva Chaturvedi, State Consultant, National Rural Health Mission, and Archana Mishra, Deputy Director (NRHM), explained that 32 per cent of the reviewed deaths had occurred in district hospitals, 25 per cent in maternity centres, 13 per cent in sub-centres and 6 per cent in private facilities. “Only 17.7 per cent of the expected maternal deaths are being reported and analysed while the remaining go unreported. Worse, in 37 per cent of the cases the cause of maternal deaths is registered as ‘other’,” they said.

“Maternal death review is a good thing and not some kind of a blame game. It aims to look into where and how maternal deaths are happening and how these cane be prevented,” says Aparajita Gogoi of the White Ribbon Alliance, working in the field of maternal health and rights.

“The government has given cash incentives to promote institutional deliveries but the communities should also be able to identify signs of emergency and understand the importance of regular ante-natal and post-natal check-ups for safe delivery. The focus should also be on the quality of care,” she said.

According to T.P. Jayanthi, Department of Community Medicine at Kilpauk Medical College (Chennai), in addition to medical causes, maternal death reviews also help us to identify the various contributory factors leading to maternal deaths. It is an important quality indicator to identify our system gaps and community barriers, including some problems that are area specific.

In her analysis of maternal death review process in 10 States between April and December 2011, Himachal Pradesh had reviewed 92 per cent of the reported maternal deaths, Uttar Pradesh 90 per cent, Orissa (79 per cent), Rajasthan (69 per cent), Assam (56 per cent), Uttarakhand (53 per cent), Bihar (38 per cent), Madhya Pradesh (39 per cent) and Chhattisgarh only 18 per cent.

In Tamil Nadu, all the 18 government medical college hospitals are being reviewed under the facility-based MDR programme. The review is being conducted by the Mission Director, State Health society through videoconferencing on the fourth Thursday of every month.

The MDR, even deaths occurring in other departments like Medicine, and Intensive Care Unit which would come under the criteria of maternal deaths are discussed along with the concerned specialist.

 


  • Communities should identify signs of emergency to make use of State incentives: NRHM official
  • MDR came out in 2010 to improve quality of obstetric care, reduce maternal mortality, morbidity

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