Tag Archives: reproductive rights

“What do women want?”

What do women want?” This rather vague question, sometimes attributed to the famous psychoanalyst Sigmund Freud (1856-1939), still crops up in today’s male-oriented societies where women occupy a second place in terms of recognition. Yet, within the context of the axiom “your health is in your hand”, this is surely a pertinent question.  It becomes equally appropriate when it is recognised that current status of health is, to a considerable degree, determined by past events, related to behaviour and the social milieu, and that today’s lifestyle has considerable bearing on tomorrow’s health status.

The scope of actions that individual women may take to protect their health will, obviously, vary according to where they live and what resources are available to them. Regrettably, majority of world’s women still live in societies where they not only occupy a second place in terms of recognition, many are condemned to play subservient roles in society, where they labour under the yoke of gender discrimination and denial of their reproductive rights. For these women, the various international instruments touching on reproductive rights, as well as the national constitutional guarantees of equality and non-discrimination, have little meaning in their lives.  They remain governed by a separate set of laws based on religion or custom, as they continue being tormented by several harmful practices, some having serious negative impacts on their health and social well-being.

But, irrespective of their status, women should want empowerment to make sound choices that have a direct and immediate impact on their reproductive health; a source of accurate information that is relevant to their immediate problem. They want basic tools for self direction and growth; knowledge of themselves: soma and psyche, their bodies’ rhythms, their sexual and reproductive health and how to protect it. They need to learn how to avoid and prevent sexually transmitted infections and unplanned pregnancy; they must be encouraged to seek knowledge of their own individual condition, ways to promote their own health, and to embrace positive health seeking behaviours.

Under circumstances such as these women would surely need a resource that provides the much needed information, but which is presented in such a style that it can be understood without a medical background.  A source that addresses some of the relevant concerns of women from age of sexual maturity to old age, seeking to empower them with information and knowledge that can assist them in making decisions regarding their sexual and reproductive health.

Obviously books and other media cannot, and shouldn’t, take the place of direct consultation with the doctor; on the other hand, they can enable a woman to have a better understanding of her medical problem and to ask their doctors more useful questions. It is their right to know all the facts that pertain to personal health care decision making.

A new addition to books that answer to the above concerns can be found at https://www.createspace.com/4183612

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“What do women want?” This rather vague question, sometimes attributed to the famous psychoanalyst Sigmund Freud (1856-1939), still crops up in today’s male-oriented societies where women occupy a second place in terms of recognition. Yet, within the context of the axiom “your health is in your hand”, this is surely a pertinent question. It becomes equally appropriate when it is recognised that current status of health is, to a considerable degree, determined by past events, related to behaviour and the social milieu, and that today’s lifestyle has considerable bearing on tomorrow’s health status.

The scope of actions that individual women may take to protect their health will, obviously, vary according to where they live and what resources are available to them. Regrettably, majority of world’s women still live in societies where they not only occupy a second place in terms of recognition, many are condemned to play subservient roles in society, where they labour under the yoke of gender discrimination and denial of their reproductive rights. For these women, the various international instruments touching on reproductive rights, as well as the national constitutional guarantees of equality and non-discrimination, have little meaning in their lives. They remain governed by a separate set of laws based on religion or custom, as they continue being tormented by several harmful practices, some having serious negative impacts on their health and social well-being.

But, irrespective of their status, women should want empowerment to make sound choices that have a direct and immediate impact on their reproductive health; a source of accurate information that is relevant to their immediate problem. They want basic tools for self direction and growth; knowledge of themselves: soma and psyche, their bodies’ rhythms, their sexual and reproductive health and how to protect it. They need to learn how to avoid and prevent sexually transmitted infections and unplanned pregnancy; they must be encouraged to seek knowledge of their own individual condition, ways to promote their own health, and to embrace positive health seeking behaviours.

Under circumstances such as these women would surely need a resource that provides the much needed information, but which is presented in such a style that it can be understood without a medical background. A source that addresses some of the relevant concerns of women from age of sexual maturity to old age, seeking to empower them with information and knowledge that can assist them in making decisions regarding their sexual and reproductive health.

Obviously books and other media cannot, and should not, take the place of direct consultation with the doctor; on the other hand, they can enable a woman to have a better understanding of her medical problem and to ask their doctors more useful questions. It is their right to know all the facts that pertain to personal health care decision making.

A new addition to books that answer to the above concerns can be found at https://www.createspace.com/4183612

Remembering my fistula patients as Kenya observes FGM Day

I couldn’t help remembering my two fistula patients in the 1970s as Kenya observed the International Day of Zero Tolerance to FGM on February 6 2012. For Kenya, this was barely four months since President Mwai Kibaki on September 30, 2011, signed into law a bill outlawing the practice of FGM. Generally, in communities where it is practiced, FGM is not viewed as a dangerous act or violation of rights, but more as a necessary step to raise a girl, and in many instances, as a rite of passage, even though it is mind-boggling how this can apply to children as young as 5 years!

Female Genital Mutilation has both immediate and long term consequences to the health of women which depend on the type performed, the expertise of the circumciser, the hygienic conditions under which it is conducted, among others. The most severe complications are usually associated with infibulations. As a means of minimising these risks the phenomenon of “medicalisation” of FGM has manifested in many countries including in Kenya, whereby these procedures are carried out by trained health professionals in health facilities. For example, a survey carried out in Kenya just over a decade ago indicated that one-third of the circumcised women admitted to being cut by a health worker (KDHS 1998). However, while medicalisation my result in fewer complications and perhaps save some lives, it must be condemned because it justifies a torturous practice built on gender discrimination and non-respect of reproductive rights of women.

Source: http://www.middle-east-info.org/league/somalia/fmgpictures.htm

One of the long-term medical complications associated with FGM, especially infibulations, is obstetric fistula- vesico-vaginal (VVF) or recto-vaginal (RVF), or both. I keep thinking about some of my fistula patients in the 1970s. During my active practice in the Department of Obstetrics and Gynaecology at the Kenyatta National Hospital (KNH) I happened to be one of two gynaecologists (the other was Dr Balwant Singh Khehar), with special interest in the treatment of urinary incontinence, the commonest cause of this being VVF. At any given time there would be one or two such cases in my ward. This condition, which arises mainly from prolonged obstruction of labour during childbirth, is a preventable problem if only all pregnant women had access to skilled care during labour and delivery. Yet it has remained a persistent problem- Dr Peter Candler, one of the gynaecologist at the King George VI Hospital (now KNH) has reported that in 1954 the commonest gynaecological condition encountered was obstetric VVF. How sad it is that decades after our independence, a substantial proportion of Kenyan women remain at risk of this tragedy.

Urinary incontinence is one of the most frightful afflictions of human kind and often results in the sufferer becoming a social outcast. Surgical treatment can be technically difficult and demanding and by no means guarantees success. I remember two teenage girls (Halima and Fatma) who were transferred from Wajir District Hospital with very large fistulae, which we had to repair in stages over several weeks. These girls almost became permanent residents of Ward 23 in the old KNH, and to occupy them they were provided each with a knitting kit and encouraged to make whatever they wanted. One morning, as I conducted my ward round one of the girls, Halima presented me with a blue knitted sweater. I was very moved by this deed. I guessed this was her way of expressing gratitude, perhaps for our compassion towards her, because she was, as yet, not cured!

The case of Halima is typical of the continuing violations of reproductive rights of young girls under the banner of culture and tradition. In terms of treating Halima’s condition, clearly we were working at the tail end of the chain of events that resulted in a damage that should never have happened. In the first place, Halima was only 14, too young to be someone’s wife and to have begun childbearing. She had been subjected to FGM-infibulation, before a forced marriage. In both situations her reproductive rights had been denied; she had been abused by the society she lived in. Then when she got pregnant she was further denied the right to health care- an opportunity to have access to skilled attendance during the antenatal period, as well as care during childbirth.

The image in this post was sourced from  Middle-East-Info.org where the strong-hearted can find more pictures of the gruesome operation.

Do HIV infected women in Kenya have the guaranteed right to free choice contraception?

Government’s commitment to voluntary and free-choice family planning practices comes to question as Kenyan HIV infected women continue being coerced to use the IUCD. The Citizen TV on November 22, 2011 ran a story[1] about a widow in Mbita who has benefited from a fish farming venture supported by a grant from an American based non-governmental organisation. The sole qualification she needed to qualify for the grant was to be HIV positive and willing to be fitted with an intrauterine contraceptive device (IUCD). It is probable that this poor widow had no choice but to accept the condition- she needed help to support her family and, to that end, would take considerable risk. The question here is whether she had any choice in embarking on this method of family planning? Is it fair to assume she was in fact coerced to accept an IUCD by the grant of much needed cash?  What is the position of the Kenya Government on the matter?

Cash for contraception? Photo: Edgar Mwakaba/IRIN

According to Prof Peter Anyang’ Nyong’o, Minister for Medical Services, family planning practice should be voluntary[1]. Service providers must educate clients on the range of choices available, and let them choose that which suits them best. “But to flash money and say take this – no, that is not how to do it!” he added. However, it is not clear what the Minister has done to arrest the coercive practices.

Coerced sterilization of HIV-positive women came to light in 2007 when 13 cases were documented in Namibia[2]. Shortly afterwards there were reports of HIV-positive women in Kenya being paid money to accept long-term contraceptive methods, particularly IUCD[3]. These activities in Kenya (which include the case in point) are supported by Project Prevention, an American NGO founded in 1997 which also pays female drug users in the U.S. and UK to be sterilized. Whereas HIV-positive women do have a legitimate need for FP services, like every other woman they are entitled to exercise choice free of coercion or manipulation through incentives. Use of incentives and disincentives to pressure poor people to be sterilized was rejected at both the 1994 International Conference on Population and Development (ICPD) in Cairo, and the 1995 Fourth World Conference on Women in Beijing. In particular, the Beijing Platform for Action states clearly that “The human rights of women include their right to ….decide freely and responsibly on matters related to their sexuality, including sexual and reproductive health, free of coercion, discrimination and violence”.

Coercion for sterilisation through incentives reached its peak in India during the rule of Prime Minister Indira Gandhi, with her government’s policy of sterilising (vasectomy) millions of Indian men who had fathered two or more children, being compensated with a transistor radio! This policy was ruthlessly and often illegally applied to the extent it came to symbolize the dangers of authoritarian rule[4]. It is notable that payment for sterilisation continues in India to this very day; for example, a medical college was recently reported to pay men that opt for non-scalpel vasectomy 1,100 Indian Rupees[5]. In Uttar Pradesh, to obtain a shotgun licence requires two people being sterilised; for a revolver licence, the price would be five. Wealthy farmers have managed to stock their armory through forcible sterilization of their poor farm hands![6]

Proponents of coerced contraception are usually driven by the wish to create an HIV-free tomorrow by preventing birth of children infected by their mothers. It is known that in Africa before the advent of antiretroviral drugs up to 40 percent of children born to HIV infected mothers were also infected. However, in Kenya, there has been an increasing access to services for prevention of mother-to-child HIV transmission (PMTCT), most often offered at antenatal clinics and at delivery. According to the Kenya Service Provision Assessment Survey of 2010, 58% of all health facilities nationwide offered some component of PMTCT services, with 33% of these facilities providing all four components for the minimum PMTCT package (HIV testing with pre- and post-test counseling, ARV prophylaxis for mother and newborn, counseling on infant feeding, and FP counseling or referral). This is increasingly reducing the incidence of perinatal transmission as well as rates of mortality among infected children. Accumulated evidence to date shows that administration of antiretroviral therapy to the mother during pregnancy, labour and delivery, and then to the newborn, as well as delivery by Caesarean section for women with high viral loads, can reduce the rate of perinatal HIV transmission to well below 10 percent[7]. What this means is that despite the many challenges not addressed here, it is possible to dream of an HIV-free generation without having to resort to cruel acts of forced contraception for HIV infected persons. Indeed this was the view expressed by UNAIDS Executive Director Michel Sidibé, during a visit to a Millennium Villages Projects (MVP) in Kenya: “We have seen that it is possible to virtually eliminate infant HIV infections in high-income countries ….Now we must apply the knowledge and tools to create an AIDS-free generation in Africa and the rest of the world.”[8]


[1]Brett Davidson and Lydia Guterman. What’s Wrong with Paying Women to Use Long-Term Birth Control? February 21, 2011 http://blog.soros.org/2011/02/whats-wrong-with-paying-women-to-use-long-term-birth-control/ accessed October 22 2011

[3]Brett Davidson and Lydia Guterman. What’s Wrong with Paying Women to Use Long-Term Birth Control? February 21, 2011 http://blog.soros.org/2011/02/whats-wrong-with-paying-women-to-use-long-term-birth-control/ accessed October 22 2011

[4] “The World: The Issue that Inflamed India” Lawrence Malkin, TIME New Delhi Bureau Chief, Monday, Apr. 04, 1977

[5] Team to probe forced sterilisation charge Express News Service

http://www.indianexpress.com/news/team-to-probe-forced-sterilisation-

[6] Outrage at guns for sterilisation policy, Indian farmers given firearms licences as an incentive to curb population growth. Randeep Ramesh in Lakhimpur The Guardian, Monday 1 November 2004 23.56 GMT http://www.guardian.co.uk/world/2004/nov/01/india.randeepramesh

Champions are Urgently Needed for Accelerated Reduction of Maternal Mortality in Africa

“It is my aspiration that health finally will be seen not as a blessing to be wished for, but as a human right to be fought for.” Kofi Annan, Former UN Secretary General

Introduction: overcoming resistance to change

There is an urgent need for champions to push for accelerated reduction of the shockingly high maternal death rates in African countries, the general improvement of maternal health in the region, and the attainment of the fifth Millennium Development Goal (MDG5). One of the major challenges for the champions will be overcoming resistance to change. Resistance to change is to be found among all levels of society, among health professionals, including obstetricians and gynaecologists; midwives; medical and nursing training institutions; statutory regulatory bodies; professional societies; health management and administration, as well as political leadership and community in general.

But why is there resistance to change? People fear change, and in medicine there is the familiar tradition of: “We’ve always done it this way.” People harbour doubts as to whether innovations actually work better than the traditional practices. There are legal obstacles, including roles and practices prescribed in laws and regulations. There are limited human, financial and infrastructure resources to sustain application of new practices; and there are socio-cultural factors, gender roles including the status of women in society, that function as barriers to change.

Maternal mortality

Recent assessments of maternal mortality show that across Eastern and Southern Africa, “the most basic and natural act of giving life causes the death of almost 10 women every hour” . In 2008, some 79,000 women died in the region in the process of pregnancy and childbirth, accounting for more than one fifth of all such deaths in the world. According to the 2011 UNICEF Report, the latest estimated figures for maternal mortality ratio in Kenya, Malawi, Uganda and Tanzania are 490, 810, 440 and 580 respectively . These unacceptably high levels of maternal deaths make it extremely doubtful that these countries will succeed in reaching all the indicators of achieving improved maternal health (MDG5) in the next 4 years.

There is need for intensified advocacy, especially towards the recognition of women’s constitutional right to life and health, and therefore their right to quality reproductive health services, which ensure that every pregnancy is wanted; all pregnant women and their infants have access to skilled care; and that every woman is able to reach a functioning health facility to obtain appropriate care in the event of complications. After all, going through pregnancy and childbirth safely is what every woman should expect.

We know that even though complications of pregnancy cannot always be prevented, deaths from these complications can be averted. Up to 75 percent of all maternal deaths can be averted if women received timely and appropriate medical care. Maternal deaths from obstetric complications can be markedly reduced if skilled health personnel and essential supplies, equipment and facilities are available. And yet, apart from Malawi, where 54 percent of births were reported to have been attended by a skilled birth attendant, in the East African countries nearly 60% of all births take place unattended by a skilled attendant. Among the poorest women the majority of birth take place unattended by skilled personnel, the proportions being 72 percent in Uganda, 74 percent in Tanzania, and as high as 80 percent in Kenya .

The direct causes of maternal deaths have long been known, and so are the interventions to prevent them. We know what works and what does not work. Clearly, what is lacking is the commitment, at all levels, to act; to make the reduction of maternal mortality a high priority; and to reflect this in resource allocations to health services, especially for reproductive health services. Professor Mahmoud Fathalla of Egypt once observed that: “Women are not dying because of diseases we cannot treat. They are dying because societies have yet to make the decision that their [women’s] lives are worth saving.” When will our countries decide?

Maternal morbidity

It has been said (though there is want of data) that for every maternal death there are up to thirty times as many cases of pregnancy related illness or disability . The lack of or poor access to, obstetric care is responsible for a major burden of maternal morbidity in African countries. Among such morbidities are the obstetric fistulae, vesico-vaginal fistula (VVF) and/or recto-vaginal fistula (RVF) which are usually the result of neglected obstructed labour.

Let me again illustrate this with the case of one of my patients, by name Halima. During my time in the Department of Obstetrics and Gynaecology at the KNH, in the 1970s, I happened to be one of two gynaecologists with special interest in the treatment of urinary incontinence, the commonest cause of which was VVF. Urinary incontinence is one of the most frightful afflictions of human kind and often results in the sufferer becoming a social outcast. Yet, this condition, which arises mainly from prolonged obstruction of labour during childbirth, is a preventable problem if only all pregnant women had access to skilled care during labour and delivery. At any given time there were one or two such cases in my ward. Halima was one of two teenage girls transferred from the Wajir District Hospital in North-Eastern Kenya, with a very large VVF; almost the entire anterior vaginal wall was missing. We had to repair this defect in stages over several weeks using grafts from other parts of her body. The two girls almost became permanent residents of Ward 23 in the old KNH building, and to occupy them they were provided with knitting kits and encouraged to make whatever they fancied. One morning, as I conducted my ward round Halima presented me with a blue knitted sweater. I was deeply moved by this deed, and for several days pondered over it. I guessed this was her way of expressing gratitude, perhaps for our compassion towards her, because she was, as yet, not cured!

Several lessons can be learned from Halima’s case. Clearly, in terms of addressing her problem, our surgical treatment came at the tail end of a chain of events that resulted in a damage that should never have happened in the first place. Halima was barely 14, too young to be anyone’s wife and to have begun childbearing. She was subjected to the severest type of female circumcision (infibulation), and given off for marriage shortly afterwards. In both situations her human and reproductive rights had been denied; she had been abused by the societal norms she lived under. In fact female genital mutilation (FGM), forced early marriage, and coerced sex were tantamount to gender-based violence. Then when Halima became pregnant she was further denied the right to health care- an opportunity to have access to skilled attendance during the antenatal period, as well as care during childbirth. How sad it is to note that, today, four decades later, many African young women continue to live under conditions that pose as much reproductive risk to their lives and wellbeing as it was for Halima.

Abortion, a fertile ground for change

In Africa, despite the fact that induced abortion takes place among women from all levels of society, the brunt of abortion-related morbidity and mortality is borne almost exclusively by the young and poor women. This perhaps explains the dilatory approach to the prevention of such mortality, where leaders don’t want to take the obvious step towards prevention of unsafe abortion. After all, it does not affect their social class. As such unsafe abortion has continued to be a major contributor to the unacceptably high levels of maternal morbidity and mortality rates that prevail in Africa. It continues to be one of the formidable challenges to the achievement of MDG5 of improving maternal health by 2015.

Yet, it is obvious that stringent abortion laws have not deterred women in need from going through with an abortion; what such laws have achieved is to push many hapless women to undergo unsafe procedures with consequent high rates of morbidity and mortality. 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, even the attendant risk to their lives. The procedure of medical termination of pregnancy is simple, short and safe when undertaken in the open, by trained persons; on the other hand clandestine abortion, usually performed by unskilled operators, is expensive, unsafe and life threatening.

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 care 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).

Increasing access to contraception is an effective primary intervention for the prevention of unsafe abortion. However, it is feared that induced abortion may continue being the only means of birth control for many women in some parts of Africa. These are women with very limited access to contraception, who include adolescents and youths who, supposedly on moralistic grounds, are denied not only the services but also information on sexuality.

“Abortion is legal but we just don’t know it”

Sadly, many of the women who suffer unsafe abortion live in countries where abortion is sanctioned under certain conditions, but they are unaware of this provision, or, because of various reasons, they cannot access safe abortion services in their countries. For example, the penal codes in Kenya, Uganda and Tanzania sanction abortion for the preservation of the mother’s life and mental health. The Constitution of Kenya (2010) has recognised legal abortion, even though abortion remains generally restricted in Kenya . It is therefore incumbent upon health care providers to ensure women do have access to what they are legally entitled.

The above notwithstanding, it is regrettable that women continue to go through unsafe abortion even when they qualify for legal termination of pregnancy. In many cases this can be blamed on the health service provider, for example, ignorance of the law, negative attitudes and biases, and conscientious objection to termination of pregnancy; or the lack of appropriate facilities including trained providers. Service providers need to recognise their ethical and legal obligations to provide women in need of abortion with appropriate information on where safe services may be obtained. Medical policies and practices can also serve to restrict access to legal abortion, for example, insistence on unnecessary procedures /practices such hospitalisation. Access to services can also be restricted due to community related factors, especially lack of awareness about the law and facilities that provide legal abortion services.

Conclusion

Clearly, time has come for a paradigm shift in the attitudes of health workers and all others who come in touch with women seeking termination of pregnancy, from the attitude driven by deep-rooted suspicion to one of considerate review of all evidence present in order to ensure women are not denied safe abortion services to which they are legally entitled. The realization of unlimited implementation of existing legal and policy provisions ought to be a key goal of advocacy groups, including the Champions for reproductive rights in Africa.

Focus on providing safe abortion services, not post-abortion care.

In order to minimize the problem of unsafe abortion and its impacts there is an urgent need for a paradigm shift in strategic planning, from the present focus on ‘post-abortion care’ to provision of ‘safe abortion services’. The present challenge for Kenya under the new constitutional dispensation ought to be ensuring all women who are legally entitled to legal termination of pregnancy do access the services without unnecessary impediments.

Addressing the problem of unsafe abortion in Kenya should significantly contribute to the achievement of Millennium Development Goal 5 on Improving Maternal Health, considering that unsafe abortion is one of the major factors behind 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 (unplanned) pregnancies in a particular community. Hence, the only sure way of effectively minimizing unsafe abortion is to ensure women have easy access to safe, effective and acceptable contraceptive information and services, backed up by policies that promote social justice and equality, enhanced status of women, as well as legislation that decriminalizes abortion.

The single, greatest challenge to addressing unsafe abortion in Africa is the lukewarm commitment on the part of governments to promote, protect and respect women’s reproductive rights, including the right to access safe and legal abortion services. This lack of political will affects the availability, accessibility, and quality of abortion-related care.

For several years there has been a mistaken notion that post-abortion care (PAC) services provide the solution to morbidity and mortality associated with unsafe abortion[i]. Consequently considerable resources have been expended on expansion of these services. Unfortunately, although PAC services can (and do) save lives, in many respects the intervention comes late, at the tail-end of the train of events that precipitated the tragedy in the first place, and as such they cannot be considered an efficient public health strategy for the prevention of abortion-related morbidity and mortality.

Prevention of unsafe abortion requires a paradigm shift in strategic planning, to a focus on provision of ‘safe abortion, not post-abortion care, services’.

‘Safe abortion’ services are those provided by trained health workers, supported by policies, regulations and a functional health infrastructure, including equipment and supplies[ii]. Performance of abortion outside these conditions constitutes ‘unsafe abortion’.

The new Constitution of Kenya, while maintaining the longstanding restrictive stance towards abortion, it nevertheless, does provide opportunities for enhancing the reproductive health and rights of Kenyan women. The Constitution 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. Although several questions arise from this statement, for example: Who is a trained health professional? Is there any emergency that does not threaten life or health of the mother? What definition of ‘health’ is implied here? etc., whatever the answers may be the Constitution has entrenched the right for a woman to have a legal abortion, though under certain conditions.  The present challenge for Kenya then is to ensure women who are legally entitled to legal termination of pregnancy can access the services without hindrance or delay.

Experience in other countries where abortion has been legalized shows that women are often denied safe abortion services to which they are legally entitled[iii]. The reasons for this include the following:

  • Provider related factors: lack of knowledge of the law, or failure to apply the law, by providers, negative provider attitudes, biases and conscientious objection, and lack of awareness (or neglect) among providers of their ethical/legal obligations to provide women in need with appropriate information on where safe abortion services can be obtained.
  • Medical policies and bureaucracy: insistence on unnecessary/outdated medical abortion techniques e.g. requirement for hospitalization, use of general anaesthesia, etc.; opposition to task-shifting, and other regulatory bottlenecks.
  • Other factors: lack of public information about the law; lack of awareness about facilities providing safe abortion services; lack of awareness (among women) of need to report early in pregnancy.

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

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

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

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