Tag Archives: Reproductive health

Barriers to enjoyment of health as a human right in Africa

The full enjoyment of the ‘Right to Health’ in most African countries is constrained by several pervasive barriers that are the subject of the current review, which urges that governments urgently adopt human rights based approaches to all health interventions in order to ensure equitable distribution of health resources throughout all sections of communities.

The Concept of Health as a Human Right: Health is a basic need for human existence and survival and as such, it is a right that must be respected, promoted and protected by government and society. The Universal Declaration of Human Rights states that “Everyone has the right to a standard of living adequate for health and well-being of himself and his family”. The concept of health as human right is stated in the Preamble of the World Health Organization’s Charter (1946), and also in the International Covenant on Economic, Social and Cultural Rights (1966). Art. 12 states of health as a human right: “the right of everyone to the enjoyment of the highest attainable standard of physical and mental health”. The Declaration of Alma Ata (WHO, 1978) stated: “Health, which is the state of complete physical and social well-being, and not merely the absence of infirmity, is a fundamental human right…. the attainment of the highest possible level of health is a most important worldwide social goal.” The right to health is fundamental to the physical and mental well-being of all individuals and is a necessary condition for the exercise of other human rights including the pursuit of an adequate standard of living. Indeed health is fundamental to enjoyment of the right to life, and the right to a healthy life is fundamental to all other constitutional guarantees.

Right to Health is a Constitutional Issue Besides the South African Constitution[i], the Constitution of Kenya (2010), which was promulgated in August 2010, is among the most progressive constitutions in Africa. It provides for the right to health care services. Article 43(1)(a) in the chapter on Bill of Rights states that every person has the right to the highest attainable standard of health, which includes the right to health care services, including reproductive health care, and in Article 43(2), that a person shall not be denied emergency medical treatment. Further, Article 27(2) guarantees equality and freedom from discrimination, and the full and equal enjoyment of all rights and fundamental freedoms. The Constitution obligates the government to take legislative, policy and other measures to achieve the progressive realization of the rights as guaranteed in the Constitution, including the right to health. The Right to Equality encompasses within itself the right of a poor patient to quality health care, regardless of their ability to pay.

Right to reproductive health care services: The concept of reproductive rights as a fundamental human right was endorsed at the 1994 International Conference of Population and Development in Cairo, Egypt. The constellation of rights, embracing fundamental human rights established by earlier treaties, was reaffirmed at the 1995 Fourth World Conference on Women in Beijing, China, and in various international and regional agreements since, as well as in many national laws. They include the right to decide the number, timing and spacing of children, the right to voluntarily marry and establish a family, and the right to the highest attainable standard of health, among others.

That reproductive rights are central to meeting international development goals was recognized by the UN World Summit of September 2005, which also endorsed the goal of universal access to reproductive health. Reproductive rights are recognized as valuable ends in themselves, and essential to the enjoyment of other fundamental rights. Attaining the goals of sustainable, equitable development requires that individuals are able to exercise control over their sexual and reproductive lives.

Right to reproductive health care services is explicitly recognised in the Constitution of Kenya (2010), just as it is recognized or implied in several international and regional instruments (see above), including the United Nations Millennium Development Goals (2000); the Maputo Plan of Action on Sexual and Reproductive Health and Rights (2006); and the Campaign on Accelerated Reduction of Maternal Mortality in Africa (CARMMA) (2009).

Barriers to enjoyment of Right to Health

1. General issues

Enjoyment of right to health in Africa, besides the inadequate financing of the health sector (see below), is indirectly constrained by several factors that operate at the regional and national levels, and mostly outside the mandate of the health sector. These include poverty, food insecurity and hunger, persistent violent conflicts and displacement of persons, heavy disease burden especially due to HIV and AIDS, and the pervasive gender-based negative traditions such as early marriage, female circumcision and lack of women’s empowerment all of which have profound effects on reproductive health outcomes.

2. Inadequate Funding to Health sector

Many governments in Africa have yet to recognise the importance of health in the overall national development, and expenditure on health is not adequately perceived as a critical economic investment alongside spending on education, agriculture or industries. Health is a critical resource for development, without which investment in all other sectors would go to waste. Poor health impacts negatively on economic productivity, through loss of labour, and under-performance due to illness. Poor health creates critical barriers to any measures intended to uplift the social wellbeing of poor and disadvantaged communities.

The levels of health budgets in most African countries do not demonstrate that health is rated as a high priority among other national needs. Despite the fact that in 2001 African countries pledged in Abuja, to increase health sector budgetary allocation to 15% of government expenditure, and although they repeated this pledge in Kampala in July 2010, in most countries national budgetary allocations for health remain far below this target. A 2007 report of the Regional Network for Equity in Health in East and Southern Africa (EQUINET)[ii] which looked into the progress made in various Southern and East African countries towards achieving the Abuja target, showed that with few exceptions most of the countries were still lagging far behind this target seven years since the declaration.

In Kenya, for the fiscal year 2010-11 just about 5.5 percent of the total Government expenditure was allocated to the ministries of Medical Services and Public Health and Sanitation. This translates to less than $1 per capita expenditure, against the recommended figure of $34 which WHO recommends for effective implementation of health interventions.

Figure 1: Real gross expenditure to the health sector, compared to overall gross Kenya Government expenditure (2007/08 – 2011/12)[iii]

A concern of particular relevance to achieving MDG5 is the disproportionate allocation within the health budget to reproductive health care services. Africa Union’s Maputo Plan of Action for Universal Access to Comprehensive Sexual and Reproductive Health Services in Africa (2007-2010) recommended an increase in per capita expenditures to about 18-24% of the $34 per capita recognized by the WHO. However, in many countries the allocation remains much below these figures.

At the international level, global assistance for reproductive health including family planning, financing has fallen in all recipient countries. Figure 2 shows that whereas there has been a steady increase in overall assistance for health, the amount focused on reproductive health and family planning has remained more or less unchanged since the year 2000.

Figure 2: Total international assistance to health and allocation to reproductive health care programmes (2000-2009)

Source: The Millennium Development Goals Report 2011

 

3. Lack of Equity in Planning for health and distribution of resources resulting in inequitable Access to Health Care services:

Physical access to services (distance to nearest Health Facility): Health care utilization is known to be greatly negatively impacted by distance to health care facilities and access to means of transportation. A study[iv] in western Kenya which explored the impact of distance on utilisation of sick child services in rural health facilities established that for every 1 km increase in distance of residence from a clinic, the rate of clinic visits decreased by 34% from the previous kilometer. According to the Kenya National Bureau of Statistics[v], on average only 6.4 percent of people in Kenya can reach a health facility within one kilometre of their residence; nearly a half (47.7%) of the people have to travel 5km or further to reach the nearest health facility, with marked regional variations (Table 1).

 

Figure 3: Proportion of community that has to travel 5km or more to the nearest health facility in Kenya

(Source: The Kenya Integrated Household Budget Survey (KIHBS) 2005/06).

For example, the proportion of people who live 5km or further from the nearest health facility ranges from 20% and 29% respectively in Nairobi and Central regions to 60%, 64% and 86% respectively in Coast, Eastern and North Eastern regions. The geographical dimension must be taken into consideration when planning health care interventions, especially when targeting socio-economically disadvantaged groups.

Affordability of services: Big disparities exist between the poor and the better off with respect to access to health care services which explains the wide gaps in health outcomes not only between rich and poor countries, but also between the wealthy and the poor in most countries. Generally, the poor lack access to health care in terms of: availability, affordability, and acceptability. Poor people are denied access to health care: (a) where public health facilities lack essential drugs, supplies and commodities; (b) where people have to travel long distances to reach health facilities, especially where public transport is scarce; (c) when fees charged for services (cost-sharing) are unaffordable, and even if there is official exemption (e.g. for pregnant women and children under five) or waiver of fees, people still end up paying on top, for drugs and transport (out-of-pocket expenditure); and (d) where people lack confidence in the services provided at local public health facilities and decide not to utilise them (e.g. poor quality services or negative provider attitudes).

The poor bear the heaviest burden of out-of-pocket health expenditures, irrespective of where they seek health care. In Kenya, data from the National Health Accounts (NHA) for fiscal year 2001/2002 showed that Kenyan households were financing over half of all health expenditures[vi], clearly justifying a conclusion that ill-health contributes to, and perpetuates, poverty because health costs deplete people’s meagre resources. In addition, there is considerable evidence to suggest that by and large public spending on health tends to benefit the better off more than the poor. Quite often it is the better off who get the most from public health services, especially hospital care. In other words, government’s investment in health services, far from promoting equity, works against it[vii].

FY 2001/2002 National Health Accounts (NHA) estimation in Kenya

Inadequate financing of the health sector and inequitable distribution of resources explain the major gaps and disparities in health indicators in most African countries, which have featured repeatedly in successive surveys such as the Demographic and Health Survey (DHS). It is important to realise that because of the size of the poorest population, countries cannot hope to achieve health-related MDGs without urgent implementation of inclusive policies in the planning of health interventions.

Addressing barriers to enjoyment of right to health

Governments must strive to address the pervasive barriers to enjoyment of right to health (including sexual and reproductive health) by all citizens by implementing human rights based approach to all interventions aimed at improving the health of the community. This will empower people to participate in decision making and health policy development, as well as strengthening their capacity to hold the health managers and providers accountable. Ministries of Health should work out clear strategies that seek to make health services inclusively available and accessible, of good quality, affordable and culturally acceptable. It is particularly important to adopt evidence-based planning which should ensure equitable distribution of health resources throughout all sections of communities.

Governments in Africa urgently need to recognise the importance of health in the overall national development, and support it by making appropriate budgetary allocation to the health sector along other critical economic investments. In addition, the international community also needs to examine their funding policies over the last decade or so, which have resulted in stagnation of financing of reproductive health especially family planning programmes.


[ii] Equinet (2007). Reclaiming the Resources for Health: A regional analysis of equity in health in East and Southern Africa. Fountain Publishers Kampala, Uganda.

[iii] Figures based on gross approved expenditure (2007/8 – 2010/11) and gross estimates (2011/12). Figures indexed to inflation at 2007 CPI.

[iv] Feikin DR, Nguyen LM, Adazu K, et al., The impact of distance of residence from a peripheral health facility on pediatric health utilisation in rural western Kenya. Trop Med Int Health. 2009 Jan;14(1):54-61. Epub 2008 Nov 14. http://www.ncbi.nlm.nih.gov/pubmed/19021892

[v] Kenya National Bureau of Statistics (KIHBS) BASIC REPORT – www.knbs.or.ke/pdf/Basic%20Report%20(Revised%20Edition).pdf

[vi] www.who.int/entity/nha/country/Kenya_NHA%202002.pdf; Adam Leive, Ke Xu. Coping with out-of-pocket health payments: empirical evidence from 15 African countries. Bulletin of the World Health Organization Volume 86, Number 11, November 2008, 849-856

[vii] Davidson R. Gwatkin (2003) Free Government Health Services: Are They the Best Way to Reach the Poor?

Factors contributing to Africa’s failure in achieving MDG5 by Japheth Mati

ABSTRACT[1]

The latest UN Report on MDGs reveals considerable reductions in maternal mortality in most regions of the world except in the sub-Saharan Africa where, despite progress having accelerated since 2000, very high maternal mortality ratios and low rates of access to universal reproductive health services, still persist. This discussion highlights several challenges that operate both at the regional and country levels. The challenges at the regional level include poverty, food insecurity, persistent violent conflicts, inadequate budgetary allocation to health sector, and heavy disease burden. At the country level are the persistent inequalities in access to health care both between countries and within individual countries. A review of the status of MDG 5 indicators particularly focusing on the known drivers of maternal mortality reductions shows that most SSA countries fall far below the targets, to the extent that they are least likely to achieve this goal by 2015. Successive national surveys show disparities which relate to wealth status and area of residence, both reflecting a lack of equitable distribution of health services. Two key challenges stand in the way of addressing these inequalities- improving human resources for health, and strengthening health systems. A critical cross-cutting determinant for both is the proportion of national budgets allocated to reproductive health services. In addition, donor-dictated policies of budgetary ceilings on certain expenditures, including hiring of health professionals, constitute another obstacle. Finally, SSA countries are particularly adversely affected by the drop in international aid towards reproductive health, and especially the financing of family planning programmes.


[1] Abstract of an invited presentation at the FIGO World Congress October 7 – 12, 2012

 

What’s happening to Kenya’s first generation born HIV-positive?

Globally, there is a general lack of awareness of the health and social challenges that face the first generation of children born HIV positive; in fact, this has not been an issue of special focus. Yet the population of that group of people is not only increasing in numbers, it is also growing older. According to UNAIDS, of an estimated 390,000 children born with HIV in 2010 globally, 90 percent of them were born in 22 countries, of which 21 are in sub-Saharan Africa, the odd one out being India[1].

There is a lot of hope that with increasing access to improved PMTCT services especially the availability of the more effective antiretroviral regimen for pregnant women and their newborn babies, fewer children will be born HIV positive. Where highly active antiretroviral therapy (HAART) has been employed, the rate has reduced to below 5 percent. As a result, in 2011 UNAIDS and PEPFAR jointly launched the Global Plan towards the Elimination of New HIV Infections among Children by 2015 and Keeping Their Mothers Alive. The plan has a main focus on the 22 countries (see above).

Source: UNAIDS and PEPFAR bring together Health Ministers and partners to advance progress in ending new HIV infections in children

For many years there was a strongly held assumption that survival from birth to adolescence with HIV was so unlikely without treatment as to be negligible, and that HIV in late childhood was very unusual. The accepted view was that the majority would die before the age of five. However, there is now accumulating evidence that children born with HIV do survive into teens and adults. In Kenya, the oldest of these children are now approaching 30[2]. In Uganda it is estimated that as many as 150,000 children are already living with HIV right from childhood. In 2006, the oldest surviving of young people born with HIV in Uganda turned 23 years old, thanks to antiretroviral therapy[3]. That same year, The Aids Support Organization (Taso) had registered 4,696 ten to nineteen-year-olds living with HIV since infancy, while another 1100 young people were receiving care at the Mildmay Centre and Mulago Hospital.

A recent article by Amelia Hill[4] entitled Teenagers born with HIV tell of life under society’s radar, HIV-positive youngsters who were infected before or at birth reveal their secret lives, highlights some of the challenges faced by youngsters in the United Kingdom who were born HIV positive. These challenges include:

  • Coping with the discovery that they are HIV positive: Usually the doctors and the parents would have withheld the information until such time as it is considered “safe” to divulge the status to the child. One 18 year old describes how at nine years old a careless receptionist at his local hospital blurted his status, and his reaction to the shocking revelation: “I remember standing there, with my mother’s hand around mine, as these feelings of complete confusion and fear washed over me. I suddenly realised that the pills my mum had been giving me every day – that I had thought were sweeties – were medicine, after that day at the hospital, I would lock myself in the bathroom when my mum took them out of the cupboard. Or I’d pretend to swallow them, and then throw them away. I know I’m killing myself,” he says truthfully, but with studied nonchalance. Inconsistency in the taking of medicines has important implication to development of resistance to specific drugs by the virus.
  •  Fear of stigma: HIV-positive youngsters have expressed worry over being branded by the stigma that is attached to HIV in society. “Society forces me to live two lives, one of which – the one where I’m honest about my status – I have to keep completely secret from the other one. It’s partly because I have to live this life of shame and secrecy that I find it so hard to take my meds….I’m angry about the stigma in society that makes me have to lie about my status“. Some adolescents have admitted having considered killing themselves.

Two studies, one in Zimbabwe and the other in Uganda have specifically highlighted some of the issues facing adolescents and young adults who were born HIV positive in those countries. In Zimbabwe, a clinical study[5] has suggested that as many as one in four children may survive into adolescence without diagnosis or treatment. Of the children under HIV care in Zimbabwe during 2008, 42% were aged 10-19 years. This study has bust the long held assumptions that HIV in late childhood is very unusual, and that survival from birth to adolescence with HIV was so unlikely without treatment as to be negligible. Among the problems most commonly faced by adolescents were psychosocial issues and poor drug adherence (which is critical in keeping the ever-changing AIDS virus at bay).

The Population Council in Uganda[6]  has addressed reproductive health needs of adolescents born with HIV. It involved a sample of 732 adolescents aged 10-19 years. The study shows that these adolescents are most likely to be orphaned, hardly any of the teens and young adults born with HIV have both their parents alive, As such they are subject to the challenges that face orphans generally. They were also found to be at risk of entry into casual relationship, using no protection, and with persons whose HIV status they do not know. Most of them conceal their status to their partners. The study reports that as many as 61 percent of the sexually active adolescents surveyed said they did not use any protective method during their first time sex, and do not know the status of their current partner.

There are lots of similarities between the findings in the two Africa-based studies and the issues raised by their counterparts in the UK report. What these limited studies clearly reveal is the inadequacy of our knowledge regarding the social, psychosocial and health challenges faced by adolescents and youths born HIV positive and their guardians.

[1] UNAIDS and PEPFAR bring together Health Ministers and partners to advance progress in ending new HIV infections in children http://www.unaids.org/en/resources/presscentre/featurestories/2012/may/20120523whagp/

 [5] Rashida Ferrand,a Sara Lowe,b Barbra Whande,b et al., Survey of children accessing HIV services in a high prevalence setting: time for adolescents to count?Bull World Health Organ. 2010 June 1; 88(6): 428–434. Published online 2009 December 16. doi:  10.2471/BLT.09.066126

Lack of concurrence between policy and practice is a serious blow to achievement of MDG5 in Kenya

What holds Kenya back in its efforts to achieve MDG 5 is staring us in the face. We just need to look and see the many areas of non-concurrence between policy and practice, for example, while on the one hand the policy is that of equitable access to RH services, in practice on the other hand, many Kenyans, especially those living in marginalized far-flung areas, have nothing close to equitable access to such RH services. This also applies to the poor irrespective of where they reside.

Among the earlier posts by Africa Health Dialogue there was one entitled “What’s in the way of achieving improved maternal health in Kenya?” in which three key barriers to attainment of improved maternal health in Kenya were discussed: the lack of equity in health planning and implementation; inadequacy of funding to the health sector; and inequitable distribution of resources for health especially financial and human resources.

Since the publication of that post, a lot has changed: first, the urgency of the matter in consideration is much greater now- there is much less time left to 2015; secondly, Kenya now has a Constitution that is specific in its provision of health as a basic right. Article 43 (1) (a) states:  “Every person has the right to the highest attainable standard of health, which includes the right to health care services, including reproductive health care”. The constitution is not saying that only the urban rich and those living in the more accessible counties have the right to the “highest attainable standard of health”. No, it is all Kenyans, wherever they may be!

In addition, we also have a National Reproductive Health Policy (2007) with its stated goal of enhancing the RH status of all Kenyans by (among others) increasing equitable access to RH services and improving responsiveness to client needs. According to the Policy all pregnant women should have access to skilled care throughout the continuum of pregnancy, childbirth and postnatal periods. Skilled attendance implies access to appropriately trained health providers whether in a health facility or through domiciliary care. It also implies access to a rapid means of referral to a higher level of care in case of an emergency. In consideration of the above, at least three questions immediately arise: (a) to what extent are maternal health services equitable; (b) are the current health interventions responsive to client needs and (c) how accessible is skilled attendance by all pregnant women in Kenya?

Review of maternal health indicators as published in successive national surveys, such as the Kenya Demographic and Health Survey (KDHS) and the Kenya Service Provision Assessment Survey (KSPA), shows that health services are far from being equitably distributed in Kenya. Women from the more marginal areas which are lacking in communication infrastructure, especially roads, and those who are in the lower socio-economic strata, are all grossly disadvantaged. In fact, these are the women who register the worst maternal health indicators (whether it be maternal mortality ratio, contraceptive prevalence rate, total fertility rate, attendance by a skilled health professional; or availability and quality of antenatal and delivery services in local health facilities, etc. etc. Unfortunately, forgetting them is not an option; Kenya will never achieve MDG5 without their contribution! That’s the way it is.

In many parts of Kenya it’s nightmarish ferrying a woman in labour to a health facility.

CASE STUDY: The following narrative is based on a true event which took place in eastern part of Mwingi in the Kitui County:

Kavata was a married mother of three, all normal deliveries at home assisted by a TBA from the neighbourhood. During her fourth pregnancy she had attended an antenatal clinic at a dispensary, beginning from the sixth month. She made a total of three antenatal clinic visits before she went into labour. At the clinic she had been advised that even though her pregnancy was progressing satisfactorily, she needed to ensure that this time round she delivered at a health centre because of her history of heavy bleeding during her last delivery. The health centre, located about 15km from her home, had only one qualified midwife, who also had other duties apart from midwifery.

Kavata went in labour at night but could not get to the health centre at that hour; the only matatu in the area made the trip twice a day, early in the morning and early in the afternoon. Walking at that time was out of the question for fear of marauding wild animals and muggers in the area. So, at 6am next day she was in the matatus heading for the health centre where she arrived at 9am. However, she could not be admitted immediately to the maternity ward because the midwife had not reported to work until 10am.

By 2pm the midwife observing that labour was not progressing normally radioed the District Hospital located about 80km away, requesting for an ambulance to transfer the patient for more specialized care. This was not possible – the only functional land rover at the hospital had travelled to Nairobi to fetch supplies. Now the only transport option available at that time for Kavata was a ride at the back of a lorry, perched on top of cowpea bags. The lorry made several stops collecting more bags on the way. By the time Kavata arrived at the District Hospital her uterus had already ruptured and she had bled profusely. Her baby had already died; she too died before anything could be done to save her life.

The big question is “Was Kavata and the many other women who are continually going her way, also expected to enjoy the “right to the highest attainable standard of health, which includes the right to health care services, including reproductive health care”? Is there concurrence between policy and practice: on the one hand the policy is that of equitable access to RH services, but on the other hand, in practice people like the late Kavata and many others have nothing close to equitable access to such services?

Implementing the Reproductive Health Provisions of the Kenya Constitution

Implementation of RH provisions of Kenya Constitution- KMA conf

How Kenya’s New Constitution is likely to impact on access to safe abortion services

Background:

The aim of this presentation is to contribute to the understanding of the provisions in the New Constitution as they relate to access to safe abortion services in Kenya, and to analyse areas of particular concern in the implementation of the Constitution. In order for Kenya to achieve Millennium Development Goal 5 on Improving Maternal Health, it is imperative that the issue of unsafe abortions is addressed, since this is a major contributor to the high maternal mortality rates in the country. In addition, complications resulting from unsafe abortion contribute to serious sequelae for women’s reproductive health such as chronic pelvic inflammatory disease (PID) and infertility.

 

The incidence of unsafe abortion generally reflects the magnitude of unwanted pregnancies in a particular community. Hence, the only sure way of effectively minimizing unsafe abortion is to ensure women have easy access to contraceptive information and services, backed up by positive legislation that decriminalizes abortion. According to UN data[ii], in most so-called developing countries like Kenya, there was a trend towards enactment of more restrictive abortion laws in the period between 1999 and 2007 (Figure 1). Whereas in nearly all countries abortion is permitted to save a mother’s life, only 60 percent and 57 percent respectively of the countries permit abortion to preserve a mother’s physical and mental health. Rape or incest, and fetal abnormalities are respectively considered in 37 percent and 32 percent of the countries; and in only 19 percent are economic or social considerations entertained. Abortion is available on demand in some 15 percent of developing countries.

 

Figure 1: Grounds on which abortion is permitted – percentage of countries

Source: (World Abortion Policies 2007 )

Constitutional provisions that are relevant to abortion services in Kenya

The new Constitution of Kenya, while maintaining the longstanding restrictive stance towards abortion[i], it nevertheless, does provide opportunities for enhancing the reproductive health and rights of Kenyan women, which if adequately implemented can significantly contribute to the reduction of the high maternal mortality rates prevailing in Kenya today, and the achievement of MDG 5. In particular, the Constitution of Kenya:

  • Is committed to nurture and protect the well-being of the individual, the family, communities and the nation[ii].
  • Guarantees reproductive health care as a right for all Kenyans[iii]
  • Commits the government to implement international conventions, and regional commitments that Kenya has pledged to support such as CEDAW[iv] and the Maputo[v] Plan of Action[vi],
  • Guarantees that every person has inherent dignity and the right to have that dignity respected and protected[vii], and
  • Guarantees equality and freedom from discrimination for every Kenyan[viii]

 

The Constitution of Kenya is explicit in the chapter on Bill of Rights regarding circumstances when abortion may be legal. Article 26 (4) states: Abortion is not permitted unless, in the opinion of a trained health professional, there is need for emergency treatment, or the life or health of the mother is in danger, or if permitted by any other written law. In other words, abortion can be permissible if in the opinion of a trained health professional there is need for emergency treatment (as in cases of severe pre-eclampsia and eclampsia), or the life or health of the mother is in danger (as in the case of severe cardiac disease, or complicated diabetes mellitus that is not adequately responding to treatment).

 

To a certain degree Article 26 (4) has widened access to safe abortion in Kenya through the inclusion of danger to ‘health’ as a ground for abortion in addition to danger to ‘life’, of the mother previously provided in Section 240 of the Penal Code[ix]. As it stands today, the Code of Professional Conduct and Discipline published by the Medical Practitioners and Dentists Board mentions, in addition, the health of the baby: “There is room, however, for carrying out termination when in the opinion of the attending doctors it is necessary in the interest of the health of the mother or baby”.

 

Restrictive medical practices

The Code of Professional Conduct and Discipline (see above) goes on to provide guidance on how medical practitioners should proceed in cases where there is ground for termination of pregnancy (TOP): “In these circumstances, it is strongly advised that the practitioner consults with at least two senior and experienced colleagues, obtains their opinion in writing and performs the operation openly in hospital if he considers himself competent to do so in the absence of a Gynecologist”. This guideline can present a serious access barrier, for example for the solitary medical worker in rural areas, where a second opinion may be a considerable distance away. Similarly restricting performance of abortion procedures to hospitals is not only restrictive but may also be unnecessary, considering that modern techniques for TOP can safely be carried out on an outpatient basis.

 

In addition, quite often in order to establish the risk to the life of the woman, a psychiatric assessment is required. This is not only discriminative to those living far from urban centres where psychiatrists are to be found. In addition, it is a process that gives the woman a label of psychiatric illness, besides being expensive, time consuming, and in many respects completely unnecessary. It is an invasion of the inherent dignity of the woman (see above). In many respects these practices serves to discourage rather than facilitate access to safe abortion services.

 

Provision of Safe abortion services[x]

The World Health Organization defines ‘unsafe abortion’ as “a procedure for terminating an unwanted pregnancy either by persons lacking the necessary skills or in an environment lacking the minimal medical standards, or both”[xi]. ‘Safe abortion’ services, on the other hand, imply the services are provided by well-trained health personnel and supported by policies, regulations and a health systems infrastructure, including equipment and supplies.

 

Almost all the deaths and complications from unsafe abortion are preventable through application of safe abortion practices. Termination of pregnancy (TOP) is a safe medical procedure when performed by trained health care providers using proper equipment, correct technique and ensuring infection prevention standards.

 

Regrettably, in many circumstances where women are legally entitled to have an abortion, safe services are not available to them due to a range of reasons, which include the following:

  • Provider associated problems and biases: a lack of trained providers (recruitment constraints; poor deployment and distribution); negative provider attitudes; stigmatization and other sanctions; conscientious objection among health workers.
  • Medical policies and practices: insistence on hospitalization; insistence on use of unnecessary or outdated techniques including use of general anaesthesia; opposition to task-shifting, and other regulatory bottlenecks.
  • Lack of knowledge of the law or lack of application of the law by providers; lack of public information about the law and women’s rights under the law.
  • Lack of awareness about facilities providing abortion or the need to obtain abortion services early in pregnancy.
  • Lack of awareness among health workers of their ethical and legal obligations to respect women’s rights, and to provide women in need with adequate information on where and how safe abortion services can be obtained.

 

Prevention of unsafe abortion and its complications

The Africa Union’s Maputo Plan of Action for the Operationalisation of the Continental Policy Framework for Sexual and Reproductive Health and Rights (2007-2010) aimed to reduce the incidence of unsafe abortion, through the following strategies:

  • Enacting policies and legal frameworks to reduce incidence of unsafe abortion;
  • Preparing and implementing national plans of action to reduce incidence of unwanted pregnancies and unsafe abortion;
  • Training service providers in the provision of comprehensive safe abortion care services where national law allows;
  • Providing safe abortion services to the fullest extent of the law;
  • Educating communities on available safe abortion services as allowed by national laws;
  • Training health providers in prevention and management of unsafe abortion

 

On the whole, there is consensus that to effectively reduce the incidence of unsafe abortion women must have easy access to contraceptive information and services, backed up by positive legislation that decriminalizes abortion. Table 1 shows a suggested three-tier scheme for the prevention of unsafe abortion and the related morbidity and mortality.

 

Table 1: A three-tier scheme for the prevention of abortion related morbidity and mortality[xii]

Conclusion 

 

This review has shown that the new Constitution of Kenya, despite the restrictive stance on abortion, does at the same time provide opportunities for enhancing the reproductive health and rights of Kenyan women. Hence, to be effective in the provision of safe abortion services, it is imperative that health care providers do familiarise themselves with these provisions in the Constitution. This will avoid the introduction or continuation of unwarranted access barriers to what should be legally availed to women in need.

Unsafe abortion remains an important contributor to the unacceptably high levels of maternal morbidity and mortality that prevail in Kenya; it is a key challenge to the achievement of MDG 5, as well as attaining the health targets set out in Kenya’s Vision 2030. In addressing the issue of unsafe abortion particular focus should be on ensuring equity in access to health care, especially for the poor and marginalised communities. Despite the paucity of supportive data, it is highly possible that considerably more induced abortions occur among the wealthier and more mature women than among the poor young single women that are often reported from public institutions. However, it is the latter that protract Kenya’s high maternal mortality rates, and who create the stiffest challenge to the attainment of national and international goals, if they are left ‘out of the loop’. In any case, the Constitution guarantees equality and freedom from discrimination for everyone.

 

Related Links


[i] Japheth Mati, New abortion law is still bad for women. STAR Thursday 29 April 2010

[ii] Preamble to the Constitution of Kenya

[iii] Article 43 (1) (a) Every person has the right to the highest attainable standard of health, which includes the right to health care services, including reproductive health care

[iv] CEDAW, the Convention on the Elimination of All Forms of Discrimination against Women, is an international agreement that affirms principles of fundamental human rights and equality for women around the world. It was adopted by the UN General Assembly in 1979 through Resolution 34/180.

[v] Maputo Plan of Action for the Operationalisation of the Continental Policy Framework for Sexual and Reproductive Health and Rights 2007-2010

[vi] Art. 2 (6) Any treaty or convention ratified by Kenya shall form part of the law of Kenya

[vii] Article 28 Every person has inherent dignity and the right to have that dignity respected and protected

[viii] Article 27 on Equality and freedom from discrimination

[ix] “A person is not criminally responsible for performing in good faith and with reasonable care and skill a surgical operation upon an unborn child for the preservation of the mother’s life if the performance of the operation is reasonable having regard to the patient’s state at the time, and to all the circumstances of the case” Section 240 of the Penal Code, Laws of Kenya.

[x] World Health Organisation. (2003) Safe Abortion: Technical and Policy Guidance for Health Systems. Geneva, World Health Organisation

[xi] World Health Organization. (1992) The prevention and management of unsafe abortion. Report of a Technical Working Group. Geneva, World Health Organization. (WHO/MSM/92.5)

[xii] Source: Mati JKG J. Adolescent reproductive health in the era of HIV/AIDS: Challenges and Opportunities. Obstet. Gynecol. East Cent. Afr. (2005); 18: 1-18


A commentary on Unsafe Abortion in Africa

Unsafe abortion remains a major contributor to the unacceptably high levels of maternal morbidity and mortality rates that prevail in Africa. It also continues to be one of the formidable challenges to the achievement of Millennium Development Goal 5 of improving maternal health by 2015. This is despite the many meetings and conferences that have addressed the issue over the last four decades, one of the earliest being the IPPF Regional Conference on Family Welfare and Development in Africa, Ibadan, Nigeria, August/September, 1976, where I was privileged to present a paper entitled Abortion in Africa[1]. Perhaps the most recent meeting is the Ipas[2] sponsored conference in Ghana (November 8-11, 2010), entitled “Keeping Our Promise: Addressing Unsafe Abortion in Africa”.

The persistence of unsafe abortion in Africa is, ultimately, perpetuated by two key factors: (a) the restrictive laws against termination of pregnancy; and (b) the limited or lack of access to adequate abortion services. Criminalisation of abortion in majority of African countries is something inherited from the colonial laws, despite the fact that the law has since decriminalised the procedure in the colonial “mother countries” (United Kingdom 1967; France 1975; Italy 1978; Spain 1985; Belgium 1990). On the other hand, it can be observed that passing of laws for or against abortion has little effect on the numbers of abortions that take place; in fact, the only difference is that the patterns of morbidity and mortality associated with abortion change. Stringent laws against abortion will not deter women in need from going through with an abortion, the only thing such laws achieve is to push many of them to undergo unsafe procedures with consequent high rates of morbidity and mortality. The procedure of medical termination of pregnancy is simple, short and safe when undertaken in the open, by trained persons; however, carried out in secrecy, usually by unskilled operators, it is expensive, unsafe and life threatening.

Obviously, like many other freedoms- legalisation of abortion may be abused, when abortion becomes a primary method of birth control, as happened in the former USSR. Increased access to contraception since the collapse of the Soviet Union, has led to a reduction in the numbers of abortions in Russia. However, it should be realised that induced abortion may still be the only means of birth control for many women in some parts of Africa, i.e. women who have very limited access to contraception, including adolescents and youths who are denied not only the services but also information on sexuality, on moralistic grounds. For such women, the desire to do away with an unwanted pregnancy can be so intense that they will avail themselves of this last resort despite the law, or the attendant risk to their lives. Sadly, many of these women live in countries where penal codes do sanction abortion under certain conditions but they are unaware of this provision; or, for various reasons, they cannot access safe abortion services in their countries.

Evidence from the Demographic and Health Surveys, over the last three decades, shows that women (and men) in most parts of Africa have increasingly taken to contraceptive practice. For anyone who chooses to practice contraception the hope is that it would not fail her or him. The shock of the discovery that this is not so, though infrequent, can drive the hapless individual seeking termination of the pregnancy. For most people it follows logic that if contraception is acceptable, then consideration for abortion should follow where there is failure- this is why in many countries medical termination of pregnancy is an accepted second line of defence against unwanted pregnancy.

Finally, in addressing the issue of unsafe abortion particular focus is needed on ensuring equity in access to health care, especially for the poor and marginalised communities, who are the main victims of quacks in backstreet clinics. Despite the absence of supportive data at this moment, it is highly possible that in many African countries, considerably more induced abortions occur among the wealthier and more mature women than among the poor young single women, that are often reported from public institutions. It is the latter that sustain Africa’s high abortion-related maternal mortality rates, and who will make it impossible to attain national and international goals, if they are left ‘out of the loop’.

Related Link

On The Abortion Question

[1] Mati JKG. Abortion in Africa. In Family Welfare and Development  in Africa. Proceedings of IPPF Regional Conference, Ibadan, Nigeria, August/September,1976.

[2] http://www.ipas.org/Library/News/News_Items/Keeping_Our_Promise_Addressing_Unsafe_Abortion_in_Africa.aspx Conference co-sponsored by FEMNET, Ghana Ministry of Health, IPPF Africa Regional Office, Marie Stopes International and the United Nations Economic Commission for Africa. A BBC interview on this conference is available on http://www.bbc.co.uk/worldservice/africa/2010/11/101109_ghana_abortion_conference.shtml

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