Thursday, 5 May 2011

Safeguarding Women's Reproductive Health or Propagating Cultural Imperialism? The Prohibition of Female Genital Mutilation Bill 2010

In December 2010 the Honourable Fred Kapondi, Member of Parliament for Mount Elgon, introduced to Parliament as a private members bill the Prohibition of Female Genital Mutilation Bill which seeks to criminalize the practice of female genital mutilation (FGM). Specifically, the bill requires the state to protect women from FGM, provide support to victims and as well as educate the public on the adverse consequences of the practice. 

FGM or female genital cutting (FGC) is a deep-rooted and widespread practice in Kenya to the extent that only 5 of the over 42 Kenyan ethnic groups do not practice one or more form of it*. It is also a practice that is jealously guarded by some groups as part of their cultural identity and any attempts to eliminate it are viewed as an affront to their identity and cultural imperialism. It is thus important to put a perspective on exactly what this bill seeks to eliminate. 

The bill comes at a time when the country has just adopted a new Constitution that affords women more and better protections for their rights including the right to health and reproductive health. Moreover, the enactment of this bill into law could be one of the mechanisms of implementing the Constitution. Outlawing FGM protects the following rights of women all of which are guaranteed under our bill of rights: life, human dignity, privacy, conscience, health (including reproductive health care) and culture. However, the greatest impact of the bill will be to safeguard women’s sexual and reproductive health.

FGM is the cause of untold suffering to millions of women worldwide with the negative consequences of its impact on a woman’s reproductive system being well documented**. Common early complications of all types of FGM are haemorrhage and severe pain which can lead to shock and death. Prolonged bleeding may lead to anemia and can affect the growth of a poorly nourished child. Local and systemic infections are also common. Long term complications are associated with infibulation, because of interference with the flow of urine and menstrual blood. Chronic pelvic infection causes pelvic and back pain, dysmenorrhoea (painful menstruation), and possibly infertility. Chronic urinary tract infections can lead to urinary stones and kidney damage. Others are the formation of cystic tumors containing hair, skin or both at the line of the scar. These are the cause of painful intercourse and they sometimes split. Childbirth is also an added risk for infibulated women, particularly where health services are limited. If de-infibulation is not performed, prolonged labour follows, which can lead to fetal death and vesicovaginal fistula, a distressing condition of urinary incontinence for which women are often ostracized by their communities***.

Apart from the physical complications, research among the girls who live in communities where FGM  carried high social value, the desire to gain social status, please parents, and comply with peer pressure is in conflict with the fear, trauma, and after-effects of the operation. In short, physical complications add to the psychological trauma with the effects varying from person to person.

Legislation against FGM is not new to Kenya. In 2001, Kenya enacted the Children’s Act which has a provision that includes a provision criminalizing FGM. This provision however useful is of a limited scope because it only protects those under the age of 18. The age limit has provided a lacuna in that the practice of FGM on a woman of majority age is not a crime and thus any person wishing to escape the reach of the law only needs to raise the age when to undertake FGM. Proponents of FGM argue that for a woman of majority age the choice to undergo FGM or not is voluntary. However, anecdotal evidence reveals otherwise. Women’s rights advocacy groups have received numerous complaints from such victims alleging use of force, violence, duress and threats of divorce as some of the methods used to pressurize women to consenting to undergo FGM. To guard against these loopholes, the new bill offers equal protection to all persons regardless of age and disallows consent as a valid defense. Furthermore, where a surgical operation is necessary for a person’s physical or mental health, culture, religion, other custom or practice shall not be a consideration in arriving at a decision.

The strength of the bill despite its brevity is its holistic approach towards eradication of FGM. The three pronged approach of protection, support to victims, and public education will be key to our success as a country to move away from the practice. And as provided, it will be imperative that the FGM policy, civil society programs and other support towards this end, respond to each of these areas. In short, this law is about safeguarding the constitutional rights of women and not about eroding cultural values. Furthermore, the constitution also allows each of us the space to question and stand away from those cultural values that are injurious and discriminatory; and a culture that puts the burden of its proliferation on a single gender while causing grave injury to health, is as injurious as it is discriminatory. In the circumstances, I have no doubt that the implementation of a law such as the one proposed will go a long way in safeguarding women’s rights.

* National FGM Draft Policy 2009
*** Ross, S. D. (2009). Women's Human Rights: The International and Comparative Law Casebook. Pennsylvania: University of Pennsylvania Press.


Thursday, 21 April 2011

KNCHR hosts media breakfast meeting on the Inquiry

On Wednesday 20th April 2011, the KNCHR public inquiry on sexual and reproductive health team hosted a media breakfast meeting at Sarova Panafric Hotel. The meeting was aimed at bringing together representatives from media houses and media agencies, as well as guest experts and the KNCHR's public inquiry team for a round table discussion on the best modalities for implementing the media component of the inquiry. 

The main objective of the breakfast meeting was to consolidate a working, collaborative relationship between the inquiry team and the media, aimed at maximizing public participation in the proceedings of the inquiry.  The inquiry team and reproductive health experts present informed the media representatives of the objectives of the inquiry. Media representatives were briefed on the concept of the inquiry, the progress made so far and the plans for the public hearings to be carried out from mid-May to July 2011. Participants were also informed on the key role the media is expected to play in disseminating information to the public, including ensuring the success of the public hearings across the country.

Some clips from the breakfast meeting as reported in the media:

Not all is bleak for Kenya's Reproductive Health Scene

A key aim of the sexual and reproductive health inquiry is to profile the success stories of Kenya’s sexual and reproductive health care system. There are many doctors, nurses, hospital administrators and staff who are working hard to provide the best services possible with the limited resources that they are allocated. Without them, Kenyans would be unable to obtain the maternal and sexual health services that they need.

According to basic health indicators compiled by the World Health Organization, Kenya’s health status has failed to show improvement in many areas over the past fifteen years. Additionally, there are significant variations in health indicators across Kenya, which implies that there is inequality in the quality of health care services across the country. There are however, a number of signs of improvement especially in the areas of malaria and HIV/AIDS control both of which pose a great challenge to sexual and reproductive health in Kenya.

HIV/AIDS Control
It is troubling that an estimated 1.4 million people are living with HIV in Kenya today, including thousands of pregnant women and children. Yet the HIV/AIDS prevalence has been continually declining from roughly 10% in the late 1990s to 6.7 percent in 2004.[1]  The decline can be attributed to the availability of low-cost medicines and improved coordination for the scale-up of targeted interventions.

The rate of HIV transmission from mother to child is between 25 and 35 per cent, without interventions – meaning that 22,000 babies are born with HIV every year in Kenya.[2] Kenya's Ministry of Health has therefore partnered with UNICEF to offer a Mother-Baby pack to prevent the transmission of HIV/AIDS between pregnant women and their unborn babies. The Mother-Baby pack has simple instructions and can be used by women who have little access to health care because they take it on their own during their pregnancy. There is also an initiative to train hundreds of healthcare professionals in the prevention of mother-to-child transmission of HIV/AIDS.

Preventive treatment of malaria during pregnancy
Intermittent preventive treatment of malaria during pregnancy can significantly reduce the proportion of low birth weight infants and maternal anaemia.[3] As a result the current Ministry of Health policy seeks to give pregnant women at least two free doses of a prophylactic drug. Indeed currently, 24% of pregnant women in Kenya benefit from this preventive treatment.[4]

Also increased use of insecticide-treated bednets has been shown to almost eliminate malaria transmission as well as reduce infant mortality, morbidity and malaria during pregnancy.[5] The use of insecticide-treated bednets by pregnant women in Kenya is roughly 40% and is just one percent lower (39%) for children under the age of five.[6] In 2003, the rate of use by both groups was under 5%. This remarkable improvement is primarily attributable to a mass distribution campaign that targeted low-income families with young children.[7] 

The right to the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being. It is recognized in important international human rights instruments including the Universal Declaration of Human Rights, the Convention on the Rights of the Child, the Convention on the Elimination of All Forms of Discrimination against Women, the International Convention on the Elimination of all forms of Racial Discrimination and the Constitution of Kenya. The right to sexual and reproductive health is a key component of this right.

It is however evident that there are still many challenges in Kenya which prevent the optimization of the right to health through the reduction of child mortality, improvement of maternal health, combating HIV/AIDS, malaria and other diseases. Intervention programs are underway to decrease malaria prevalence, prevent HIV-transmission and generally improve access to reproductive health services, though it is necessary to evaluate the effectiveness of these programs and scale-up those that are having a positive impact on reproductive health.

Wednesday, 13 April 2011

Reproductive health services endanger the lives of Kenyans

The government, which controls slightly over half of all health facilities in the country, has failed on several occasions to take responsibility for the reproductive health of its citizens. This leads to severe human rights violations in health facilities and cases of mothers and newborn babies losing their lives.   

According to a joint report by the Center for Reproductive Rights and FIDA Kenya, various factors account for this including: understaffing; the imposition of user fees; congestion; lack of most basic supplies such as anesthesia, gloves, syringes, surgical blades, soap, disinfectant, speculums and bed linens; negligence; and malpractice, which includes unreasonably painful and poorly performed stitching sometimes without anesthesia. Evidence for this can be seen in the choices of 56% of Kenyan women in the slums and the rural areas to deliver in their homes instead of at health facilities. It is not surprising then that Kenya has a high maternal death rate: 488 maternal deaths per 100,000 live births (according to the latest 2008/9 KDHS report).

A recent report by the Partnership for Maternal, Newborn and Child Health (the countdown to 2015) revealed that at least 21 mothers, sometimes the sole breadwinners of their families, die daily from childbirth-related complications in Kenya, from delivery due to poor hygiene (that is responsible for about 22 % of deaths), from bleeding (estimated to be the cause of 30% of maternal deaths), while high blood pressure, malaria and HIV/AIDS contribute to the remaining percentage of maternal deaths.

Interestingly, the condom shortage reported in parts of the country last year went unheeded until it developed into a countrywide crisis this year. Some of the negative outcomes that may arise as a result of the shortage include reversals in gains made in the war against HIV/AIDS and an increase in unwanted pregnancies which expose poor and young mothers-to-be to unsafe abortions and unsafe deliveries.

Friday, 8 April 2011

Can innovations in medicine help save rural women from haemorrhage during childbirth?

A community hospital in a Kenyan town
Last Friday the Daily Nation reported on a pilot initiative carried out by the Kenya Obstetrical and Gynaecological Society (KOGS) and Venture Strategies Innovations (VSI) to distribute a drug called misoprostol - a simple three-tablet dose to treat postpartum haemorrhage (PPH) - in rural communities in Kitui and Maragua. PPH, which is essentially excessive bleeding after delivery, is one of the leading causes of maternal death in Kenya and globally.  

The World Health Organisation’s (WHO's) recently published Priority Medicines for Mothers and Children 2011 - the first publication of its kind from the organisation - prioritises medicine for PPH and lists oxytocin as the drug of choice in this regard. However, while oxytocin injections can only be administered in a health facility, misoprostol tablets can be distributed to women for use during home births. According to the 2008/09 KDHS, only 43% of births around the country occur in a health facility. And while 75% of urban women deliver in a health facility, only 35% of rural women do so. Worryingly, these statistics have not changed significantly over the past ten years. For this reason, misoprostol has the potential to save the lives of many rural women.

The initiative’s partners argue that “the distribution of this drug at the antenatal care visits and through community midwives should be scaled up throughout Kenya” (quoted in Daily Nation, Three-tabled dose to stop bleeding and save women's lives, 31st March, 2011).  This prompts us to think about how the government can best fulfill Kenyan women’s right to health. While the right to health can be achieved ‘progressively’ depending on a country’s level of resources, there is international consensus that governments have at least some core obligations that must be achieved. These include the obligation to ensure the equitable distribution of health facilities, services and goods [i]. Misoprostol is inexpensive and easy to distribute. But it is also associated with more side effects than oxytocin. For this reason, it should not be misconstrued as an alternative for assisted delivery with a skilled birth attendant, nor should it detract efforts aimed at improving equal access to health facilities for all women across the country. Rather, efforts should be centred on identifying how it can be used in conjunction with promoting delivery at health facilities. 
 
[i] See U.N. Committee on Economic, Social and Cultural Rights, General Comment No.14, at paragraphs 43-44. 

Monday, 28 March 2011

Beginnings: The KNCHR and the Sexual and Reproductive Health Inquiry

Maternity unit at a provincial general hospital in Kenya
After receiving a number of complaints about sexual and reproductive health rights violations in Kenya, particularly in health facilities, the KNCHR decided to conduct a public inquiry since the complaints received demonstrated systematic violations affecting a majority of the public. Such an inquiry presents an opportunity for both providers and consumers of sexual and reproductive healthcare to give their views so that the KNCHR can come up with recommendations for all stakeholders to work towards improving the status of sexual and reproductive health in Kenya.

The public inquiry team began the public inquiry process with a comprehensive literature review including analyses of various legal and policy frameworks that are relevant to the Kenyan context. Some of these were:
  1. The Constitution of Kenya
  2. The Adolescent Reproductive Health & Development Policy
  3. Millennium Development Goals
  4. Protocol to the African Charter on Human & People's Rights on the Rights of Women in Africa OR The Maputo Protocol 
The team then organized a half-day stakeholders' forum in order to discuss the objectives of the public inquiry and to get additional input from others working in the field of sexual and reproductive health. This forum comprised representatives of both the private and public sectors and began the KNCHR's engagement with some members of civil society around the public inquiry. The objectives of the inquiry have been narrowed down as:
  1. To establish the legal and policy framework governing the implementation of sexual and reproductive health rights in Kenya and the effectiveness thereof
  2. To assess compliance by the government and non-state actors in sexual and reproductive health rights in Kenya
  3. To determine the extent of sexual and reproductive health awareness and utilization in Kenya
  4. To identify and document cases of discrimination in and violation of sexual and reproductive health rights in Kenya
Following the stakeholders' forum, the team then went out into the field to carry out pre-hearing visits/assessments in which they sampled 6 regions across Kenya: Nairobi region & its environs, Coast region, Nyanza & Western regions, Central & Eastern regions, North Rift Valley region and North Eastern & Lower Eastern regions. The team did assessments of various health facilities, NGOs and individuals in all these regions and is currently putting together a summary of their findings. Basically, the commission wanted to find out:
  1. Are healthcare providers guided by existing laws and policies in their service provision? Do they feel that they are appropriate? 
  2. Do healthcare providers ensure the highest quality of standards in the provision of sexual and reproductive health? Why/Why not? How?
  3. Are Kenyans aware of their sexual and reproductive health rights? Do they make claims of them (e.g. reporting incidences of medical negligence)? 
  4. What violations of sexual and reproductive health have occurred and what has been/can be done about them? 

Comments, contributions and criticisms are VERY welcome!

There has been quite a bit of media coverage over the past few months on various sexual and reproductive health issues, such as maternal mortality and unmet contraceptive needs. You can check out some of these stories in our News section.