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The Bleak Mental Health of a Child Bride

January 31st, 2013

Let me tell you the story of a girl. We will name her Ana. Ana is married at 13 to a man who is 22. She leaves her family to live with her husband. She stops attending school and never sees her friends. Her husband forces her to have sex at 13 years old. She doesn’t know what is going on but she knows it hurts and that she doesn’t like it. They don’t use protection and she becomes pregnant. During her pregnancy, her husband’s parents beat her. During labor, she develops a fistula and is labor for three days until she almost bleeds out while giving birth. Her baby is a girl and her baby is taken from her and killed. Try to imagine Ana having good mental health. It is impossible to do, at least it is for me. Ana’s is a tragic story but it is not a unique story. Far too many girls around the world share a story all too similar to Ana’s. They are plagued with mental illness as a result of having been forced to marry as a child and it is debilitating to their health and happiness.

Fifty-one million girls worldwide are child brides. Twenty-five thousand girls under the age of 18 are married everyday. Many of these girls are married to men who are significantly older. Many of these girls are under the age of five. Their psychological health suffers because they are denied a normal childhood period where crucial development typically occurs and are faced with adult issues as children, when they are not mentally equipped to handle them yet. Child brides lose their virginity at a very young age, usually forcibly, before they are emotionally ready. Girls who marry young, typically have children young. Most child brides become mothers while they are still children themselves, not physically or mentally ready to bear a child. Girls under 15 are five times more likely to die in childbirth. Girls know how common complications are in childbirth and this can cause extreme anxiety for them. Child brides are often punished for having female children or subjected to unsafe abortions if it is found out they are carrying a girl. Some child brides are forced to murder their female children after they are born by smothering or poisoning them. Child brides are more likely to experience domestic abuse than women who marry later. Child brides are often forced into prostitution and beaten with they object.

Child marriage is a trigger of many mental illnesses due to the list of stresses above. The violence and related health issues can trigger post traumatic stress disorder. Depression is also common because the girls feel they have no control over their own life and are isolated from their family and peers at a young age. Child marriage denies girls the opportunity to make choice central to their lives. Choices define us and allow us to realize who we are and what we can be. The family pressure and sexual coercion associated with child marriage can cause extreme anxiety along with other mental issues. Fear of marriage and the related sexual experiences can also cause extreme anxiety in girls. Giving birth can trigger anxiety disorders as well because of the fear of fistulas, extended period of labor and death from complications. Child brides commonly have sleep problems stemming from their anxiety and eating problems associated with depression. Mental illness is more common among child brides than women married as adults. It is every person’s human right to physical and mental well-being and the practice of child marriage robs these girls of that right by inflicting mental illness on them.

Child marriage is a deeply rooted social phenomenon in many parts of the world that we need to work to break down but this is going to be difficult and take time. I feel that we need to mediate the harmful psychological effects of child marriage while we are trying to end it. If child brides had an outlet to discuss their emotions, it could give them a way to process their feelings and retain better mental health. Also, giving child brides something they can control in their life to replace the lack of control they feel over their marriage could potential improve their mental health. Effective interventions need to be created and implemented because child marriage is causing a critically high level of mental illness in girls around the world.







Sexual Cleansing in Zambia

January 31st, 2013

Upon the death of a husband, for the Tonga women of Mozambique, Zimbabwe, and Zambia, a widow is “inherited” into her husband’s family and must participate in traditional inheritance practices that breach her right to protect her body, wellbeing, and future. The Tonga represent one million of Zambia’s 13.3 million person population.[2] Sexual cleansing—a major aspect of inheritance procedures— is a ritual among the Tonga in which widowed women are forced into sexual relations that are often unwanted. In order to rid herself of her late husband’s ghost, a widow must engage in sexual intercourse with a member of her late husband’s family. Sexual cleansing is also meant to prevent the woman from going insane should she have a future sexual partner.

The man who will participate in the sexual cleansing receives a cloth from his wife, which symbolizes her permission for him to have sexual intercourse with the widow. In the event the wife does not give permission, many men have been reported to steal a piece of cloth from his wife to present to the widow. On the morning after the man and widow perform the sexual cleansing, the relatives of both families come to the widow’s house. The man typically throws a match out of the window and makes the declaration, “this my home,” symbolizing the completion the ritual. The man, if single, often has the option to marry the widow should he so desire or keep her as a second wife.[1]

Similar to sexual cleansing, another encroachment on a widow’s rights is levirate marriage. A widow is often forced to marry her deceased husband’s brother in order to propagate the familial lineage. While this practice is less common today, it is still prevalent in the rural and impoverished areas of Zambia.

Sexual cleansing is a custom that is a severe breach of a woman’s sexual freedom. A woman has no choice on whether or not to participate in these traditional inheritance practices. Many women believe that if they do not participate, they will suffer an early death or go crazy. But others, like Theresa Chilala, 79-year-old woman in Zambia, feel otherwise. Chilala refused to participate in sexual cleansing after her husband’s death due to her Catholic faith and her fear of contracting HIV. Consequently, she was forced by her in-laws to evacuate her husband’s property and lose her livestock. For the next sixteen years, her in-laws buried the dead of their family on the widow’s property. When Chilala sought retaliation through part of the national justice system, Zambia’s Lands Tribunal, she lost the case as the court ruled in favor of customary practices.[2] The courts supported the in-laws decision to evict Chilala from her home, subject her to a life of poverty, and abuse her by creating a graveyard on her homestead. Four years later, a group of chiefs finally banned her in-laws from burying people on Chilala’s property.[3]

In addition to the infringement on women’s control of their bodies, this sexual practice leads to the spread of HIV in a country where 1 in 4 adults are already HIV positive.[4] The societal infrastructure impedes the woman’s ability to resist sexual cleansing or suggest condom use. This is the sad reality for Maria Moomba, a sixty-year-old widow in the Southern Province who had enjoyed a long and faithful relationship with her husband. After her husband passed away, she was forced to have sexual intercourse with his nephew, who infected her with HIV. “I tried to resist but I was powerless,” Moomba stated, likening the experience to having sex with a child.[5] In addition to not being able to afford antiretroviral drugs, Moomba’s fifteen herds of cattle were stolen by her in-laws, effectively eradicating her source of income. Property grabbing, where widows’ possessions are revoked by their in-laws, is reflective of a common view that widows are witches and corrupted with greed.

The practices that restrict a woman’s right to sexual freedom are imbedded in cultural tradition. In future blogs, I will discuss the legislation and education surrounding sexual cleansing as well as its future trajectory.

[1] Sexual Practices and Levirate Marriages in Mansa District of Zambia. Kalinda, Thomson. Electronic Journal of Human Sexuality. Volumeb 13. 23 March 2010. http://www.ejhs.org/volume13/leverite.htm

[2] Hambuba, Carlyn. Zambia: Widow defies ‘sexual cleansing’ custom. Women Living Under Muslin Laws. 26 Nov 2006. http://www.wluml.org/node/3363.

[3] Hambuba, Carlyn. Zambian Widow Defies Custom and Life Amid Graves . Women’s E-news. 26 November 2006. http://womensenews.org/story/traditions/061126/zambian-widow-defies-custom-and-life-amid-graves#.UQtvhlpU7FQ.

[4] Zambia. Aids Healthcare Foundation. http://www.aidshealth.org/africa/zambia.

[5] Mwizabi, Gethsemane. Zambia: The Ugly Face of Sexual Cleansing. 26 Nov 2004. http://allafrica.com/stories/200411290912.html.

In Exodus: In Their Own Words

January 31st, 2013

For this week’s post, I’d like to try something different. One of my self-imposed challenges for this course was to try harder to look at the material from a scholarly perspective and to work on developing my reactions into more than emotion. However, after reading through two resources that are “in the refugees’ own words,” I would like to use this post to let the population I’m exploring to speak for themselves. Below are a list of quotes taken from men of refugee camps as complied by the UNHCR; I wanted to share them with my audience (as well as the publication), along with a few drawings, and hopefully gauge your reactions. I think how these men and women perceive their health and safety is most important, and they should be consulted in the quest to find solutions. Though I planned to discuss interventions, I want to give you perspective sof the displaced people I have been learning about so that we can develop a more thorough idea what needs to be accomplished.

“There were three government soldiers with guns. One of them saw me and asked, ‘Where are you going? I said I was looking for wood. … Then he raped me.”

“They rape our environment, and, you know, they get raped,” Hyndman recalls a Kenyan police officer telling her.

“In response to the question “What is your life in the camp like?” A woman replied: “Do you know about hell? This place is not hell. It is worse than hell.”

“Young girls are in danger especially if they are beautiful. Police in plain clothes come to the sheds at night with villagers. If the girl has a father or a brother they say that if the girl will not have sex with them they will take the father and brother and beat them and falsely accuse them and then they will have to pay a large bribe or go to jail.”

“If someone in the family got seriously ill, I don’t know what we would do, we’d depend on God”

“When a displaced woman arrives in the city she has three choices: prostitution, begging or starvation. Which one would you choose?”

“We live inconstant terror, unable to protect ourselves and our children.”

“She was twelve years old when she got pregnant and she died because her hips were not wide enough to give birth. There are so many teenage pregnancies and there is no one who can perform caesareans.”


How do these words and images make you feel? Interested in the full reports? Use the links below. Also, I would like to express my gratitude for the comments I’ve received thus far. I promise the interventions are coming soon. I wasn’t planning to be attached to the exploration of sexual violence in refugee camps, but if I decide to branch out to other issues within camps, I promise I will not you hanging without doing an intervention piece first!


UNHCR The Dialogues Book (Survivors, Protectors, Providers: Refugee Women Speak Out)

UNHCR Refugee Consultations, Bangladesh, 2007

Michele Lent Hirsch’s The Safest Prey

The Consequence of Frequent Sex

January 31st, 2013

In my last blog, I focused on the beginning of the maternal health narrative by looking at reproductive coercion and the countless women that are forced to have sex and suffer from resultant disease, unwanted pregnancy, or death. I came to the realization that improving maternal health outcomes is contingent on empowering women in sexual situations and at the moment, increasing access to contraception and safe abortions. Basically, in order to reduce the level of maternal deaths we must reduce fertility rates, and the overall population.

While conducting research on interventions necessary to combat high fertility rates, I frequently came upon the economist theory called demographic transition. I found it highly insulting for people to theorize that fertility has a causal link to economic freedom and education—especially because there was no information on the role of contraception in preventing fertility rates. What this theory lacks, is an acknowledgement of human nature. We have SEX, and we have it often; therefore, without proper access to contraceptives, some women bear the burden of having unwanted children and are further impacted by poverty.

A recent paper by Dr. Martha Campbell called “Do Economists have Frequent Sex,” explored the implications of this flawed economist-supported theory. She found that “In many countries women still live in the depths of poverty and have little access to contraception. Such a woman does not have enough power to tell her husband “no sex tonight”—lest he treat her roughly or take on another wife or girlfriend—leaving her and her children with less food.  Oddly, economists seem to miss the realities of this sad situation, where women have few options about their childbearing.[i]

The dangers of childbirth and the rampant fertility rate are changing the family structure by eliminating stability. Countless mothers are dying leaving children to fend for themselves. Other mothers are ostracized because of fistulas caused by complications from childbirth.

This sad reality is very evident in Ukpor—a small rural village in Nigeria where my father grew up. I have visited many times growing up, but it seems that every year the situation becomes more stratified. It seems that each year more of the forest is cleared for more modern structures, while the plight of the local families continues to increase.


Ukpor, 2008

The picture captures the situation perfectly. The young girl pictured below is the fourth daughter of a family my father grew up with. Her mother, though aged feels pressure to continue bearing children in hopes of producing a son. I took this picture in 2008, and I can only imagine where she is now, and what her life has become.

Direct access to contraception and safe abortions are at the heart of the maternal health issue.




An Exploration of International Lesbian Rights: Intervening on U.S. Lesbian Domestic Violence

January 31st, 2013

An Exploration of International Lesbian Rights: Intervening on U.S. Lesbian Domestic Violence

My last blog focused on the progress that the United States has made towards decreasing the discrimination towards lesbian/queer women and some of the specific issues that the US can still improve upon. One such topic, though only slightly mentioned last week, is the issue of lesbian domestic violence. And continuing along the line of thought that lesbian issues in the U.S. are more directly relevant to this blog’s audience, I decided that this week’s blog would highlight some domestic violence intervention programs in the U.S.

When I first came across the term “lesbian domestic violence” I was a bit perplexed. One part of me was a bit surprised that such a thing even existed, and another part of me was a bit surprised that it was a phrase that so few people seem to have heard of. In fact, 17-45% of lesbians have reported specifically physical violence from their partner (Rose). These numbers are similar, or even slightly higher than the reported domestic violence in all American adults. This number specifically surprised me. Since women are generally viewed as more warm, tender, and empathetic than men, the idea that a woman in a same sex relationship would purposefully hurt her partner seemed strange to me. Yet, the reasons for lesbian domestic violence still boils down to one person wanting to gain and maintain control over their partner, usually to compensate for their fears of abandonment or loneliness, just like heterosexual domestic violence (National Coalition of Anti-Violence Programs 1998). Still, lesbian partner violence has unique issues that need to be addressed. One such example is the unique threat to “out” the partner to her friends, family, or employer. Furthermore, in a homophobic environment, lesbian victims may be less willing to seek help or may find it more difficult to seek help from the police or victim service agencies. For this reason, lesbians even more rarely seek help in domestic violence situations than women in heterosexual domestic violence situations (Ristock 1997).

While lesbian domestic violence awareness is not as high as it should be, there are some intervention programs that specifically strive to help in these cases. One necessary intervention strategy is to provide support, legal aid, and protection for the victims themselves. One such organization is The Network/La Red. This organization was formed in 1989 by a group of battered lesbians in Boston with the mission of addressing violence in the lesbian and bisexual community. The organization specifically addresses the issue that lesbian domestic violence is not well-known or even accepted to be a real phenomenon. Community members offer their homes as safe spaces for victims and their children and support and information groups are often held. The Network/La Red also offers pro-bono/low cost attorney services and court accompaniment. Overall, as a survivor-led program, The Network/La Red provides the opportunity for battered lesbian women to seek shelter and advice.

Yet another important piece of reducing lesbian domestic violence includes supporting the abusers themselves. As it the case for any domestic violence situation, it is fairly easy to simply focus on the needs of the victims and neglect the reasons violence began in the first place. I would argue that it is equally important to offer support, education, and other services to the abusers as well. Wellspring Family Services, based out of Seattle, is one example of an organization that aims to provide support specifically for the individuals in a relationship that have exhibited controlling or manipulative behavior. While the organization holds support groups for men, fathers, and children, another specific group targeted are lesbian women. The program aims to help these women learn how to have healthier relationships by changing their beliefs about control and respect and emphasizing empathy.

Overall, while lesbian domestic violence is as prevalent in the United States as heterosexual domestic violence, it is an invisible yet critical issue because of current homophobic attitudes in society. Still, there is hope of progress in the form of various intervention programs focused on providing support and services to both the victims and the abusers.

To learn more about The Network/La Red, visit http://tnlr.org/about/mission-anti-oppression-principles/

To learn more about Wellspring Family Services, visit

National Coalition of Anti-Violence Programs (http://www.avp.org). (1999). Lesbian, gay, transgender and bisexual domestic violence in 1998. New York: NCAVP.

Ristock, Janice L. (1997). The cultural politics of abuse in lesbian relationships: Challenges for community action. In N. V. Benodraitis (Ed.), Subtle sexism: Current practice and prospects for change (pp. 279-296). Thousand Oaks, CA: Sage.

Rose, Suzana. “Fact Sheet: Lesbian Partner Violence.” Fact Sheet: Lesbian Partner Violence. National Violence Against Women Prevention Research Center, n.d. Web. 31 Jan. 2013.

When Mom is Sad: Maternal Depression in Low-Income Countries

January 31st, 2013

We spoke in class this week about the trajectory of a woman’s life in developing countries, a path that is disadvantaged from birth due to gender. In thinking of topics in mental health that begin early in life, I chose to focus this blog on maternal depression. Postpartum and peripartum depression influence the lives of mothers and their children and damage the bond between them. In developing countries, precipitating factors and lack of treatment make this danger even sharper. This post will aim to outline the problem of maternal depression in low-income countries, and to introduce some  proposed interventions.


Maternal depression has myriad effects. Concerning the mother’s health, experiencing postpartum depression means it is more likely that a woman will be chronically depressed (1). Children of depressed mothers will be less likely to develop crucial secure attachments with their parent. This, in turn, will impact on their cognitive development. Studies note that mothers in “low-income countries” experience life stressful situations that lend to depression. Researchers cite economic stress, poor marriages, and domestic violence in particular (2, 3).
Both sets of researchers also mention the birth of a female child as a cause of depression in and of itself. This is particularly germane to our discussions in class this week; we were able to see the economic and social burden of becoming pregnant with a female child. While the event of a child’s birth should be joyous, for women in low-income countries it can be the source of maternal depression.


It is interesting to consider the variations in treatment of maternal and postpartum depression in the western world versus low-income countries. Depending of course on socioeconomic status, depressed mothers in the “developed” world often have access to treatment and drugs to ease their symptoms and their minds. Their disease is acknowledged and their plight given the consideration it requires. Mothers living in impoverished areas, in contrast, lack these benefits. According to research from Purdue University and others, in developing countries “antidepressants are infrequently used because of the lack of psychiatrists, high cost of medications, and low rates of patient adherence” (source 2, p. 4). The patient adherence factor intrigued me; why would patients, if given access to these treatments, not comply? The answer may lie in social stigma or a lack of recognition that they suffer from a treatable disease rather than simply sadness. A lack of education about the efficacy of antidepressants may also be to blame.


What can be done about maternal depression in low-income countries? Researchers acknowledge that social factors leading to mental unrest must be targeted. A future mother’s health should be monitored during her pregnancy, and there should be a focus on the interaction between mother and child upon the birth of the child. One suggested pathway is to first focus on social factors, then to give still-depressed mothers some form of psychological counseling, and finally to turn to drugs (2). This seems a wise approach, especially considering low rates of patient compliance with antidepressant medication. As part of counseling programs for these women, researchers also advocate a specific focus on gender (3). If the birth of a female child is a source of depression, efforts should be made to alleviate that stressor.


In considering these suggestions, I found myself torn. On the one hand, I agree with a holistic approach to maternal depression in low-income countries. It must be acknowledged that economic, familial, and social stressors disproportionately burden mothers in low-income countries. Addressing these factors presents an enormous challenge; how, for instance, can one mediate the effects of long-standing and deep-rooted discrimination against female children? How can one lower the incidence of domestic violence to improve the health of mother and child? Mental health is intricately connected to social environment and influences. Improving circumstance will improve mental health. That transition may come slowly, but better circumstances certainly lend to improved mental health.


Another perspective: social factors are relevant and important, especially for mothers in this situation. There are, however, genetic factors that lead to depression, which is often chemical in origin. The power of antidepressants should not be underestimated, and perhaps this approach will improve lives more quickly than comprehensive social change.


Then again, there really is no need to decide.  Both approaches are crucial, and both depend on culture, time, tradition, and the hope for change. Improved economic status, aided by education, will help women to reduce financial stress. The economics of medicine must be changed to create accessible treatment. Bias against female children must be shifted so that a child’s birth becomes a happy event rather than a distressing one. Mental illness must be de-stigmatized for women to accept it and take medication.


This is a complex issue, but an important one to realize and take steps to address. The first step in any intervention should be to meaningfully acknowledge the problem at hand.

1. Murray, L. Sinclair, D., Cooper, P., Ducournau, P., & Turner, P. 1999. “The socioemotional development of 5-year-old children of postnatally depressed mothers.” Journal of Child Psychology & Psychiatry, 40, 1259-1271.

2. Wachs, T., Black, M., & Engle, P. 2009. “Maternal Depression: A Global Threat to Children’s Health, Development, and Behavior and to Human Rights.”  Purdue University, University of Maryland School of Medicine, and California Polytechnic State University.

3. Patel, V., Psych, M.R.C., Rodriguez, M., & DeSouza, N. 2002. “Gender, Poverty, and Postnatal Depression: A Study of Mothers in Goa, India.” American Journal of Psychiatry 2002: 159: 43-47.

Finding Common Ground: the interplay between religion and intervention

January 31st, 2013

Keeping Context in Mind

From grassroots organizations disseminating general information about sexual and reproductive health, to targeted initiatives like FACE AIDS that focus on specific practices or diseases, the importance of educating women about healthcare seems obvious. But what happens when health education comes into conflict with religious tenets? No matter how convincing the healthcare curriculum, confronting the divine requires more than soliloquies about safe sex.

1. Dangers of ignoring religious context

Given that I fall somewhere in the ambiguous gap between agnosticism and atheism on the spirituality spectrum, I fall into the trap of religious insensitivity too often. When religious tenets conflict with science or health principles, I’m not as patient as I should be. Although such minor intolerances may only minimally impact my everyday life, this attitude scales. In the context of healthcare, perpetuating the conflict between religion and science will only weaken attempts at intervention. Due to the strong – if sometimes unfounded (as we saw in the case of Female Genital Mutilation) – connections between religious convictions and health practices, maintaining a balance between respect and intervention is vital. Unfortunately, not all programs take cultural context into account. Despite lofty intentions, efforts that conflict with deep-rooted conventions are doomed to waste resources and end in failure.

Consider the case of the Sabiny people in the Kapchowra district of Uganda, where external groups have been leading efforts in health education without success. Even after 60 years of disseminating information about the health risks of Female Genital Manipulation, the practice remains widespread largely due to a lack of cultural sensitivity. Rather than health workers attempting to work with the community to improve wellbeing, organizations are often seen as arrogant outsiders passing judgment on culture, to the extent that “one campaign was actually linked to a dramatic increase in the number of girls who underwent FGM” [1].

For similar reasons, although an important first step, legislation is often not enough to instigate change in cultural practices. “Moves should be made to gradually replace the practice but mere repression through legislation has been shown to be counter productive” [2]. Simply banning practices like FGM is not enough to change outlooks, and will likely generate community resistance.

2. Religion as a platform for healthcare interventions

External medical agendas and local religious doctrine are thus typically considered at odds. But more often than not, both work towards the same end goal of fostering personal and community wellbeing. This shared objective proves that, in the correct context, health interventions and spiritual tenets can be mutually reinforcing.

At an individual and small community level, religion already fortifies disease management and care. Personal belief in a guiding force, as well as faith-based support groups, offer potential salves for the psychological impacts of the poor health. In this way, religion serves as a coping mechanism, especially in terms of chronic disease management. In the case of HIV/AIDS, for example, “HIV’s uncertain course and terminal outcome make it a situation where people may see themselves as having little personal control, a circumstance where people often turn to religion for answers” [3].

But can the role of religion extend beyond the realm of existential comfort into real-world, pragmatic interventions? Studies of traditional interactions between religious groups and healthcare reveal that the two forces often cooperate. For example:

The contributions of religious groups to community health have also been substantial. Such groups have been effective avenues for promoting health programs because (1) they have had a history of volunteerism…(2) they can influence entire families, and (3) they have accessible meeting-room facilities [4].

3. Potential Intervention

FGM Therefore rather than sidestepping the issue, the power of religion in specific communities should be harnessed in working toward healthcare goals. In order to “achieve success in preventing the continuation of FGM/C, it is necessary to understand the forces underpinning the practice, such that information, messages, and activities can be tailored to their audience accordingly” [5]. Keeping the above discussion in mind, we might consider the following paradigm for a more effective intervention to decrease the practice of FGM in the Kapchowra district of Uganda:

  1. Religious Research – before any healthcare education or intervention program is put into action, the appropriate social science research should be conducted. If the majority of individuals connect a medically questionable practice with longstanding religious beliefs, then confronting the procedure alone will not be effective. In the context of FGM, “there is no specific support for female circumcision in the Koran…There are also millions of Muslims in India, Russia, China, Afghanistan, Turkey, Libya, Jordan, Iran, and Iraq who do not practice any form of FGM” [2]. Misconceptions about religious support for the practice must be understood before they can be dispelled.
  2. Religious education – if religious leaders can verify that FGM is not supported by religious doctrine, a dialogue between religious leaders and health workers can be established. Encouraging spiritual leaders to explain the lack of support for FGM from a religious perspective will more effectively change the minds of adherents than health advice from outsiders.
  3. Legislation – although it must be coupled with social efforts in order to be effective, legislation is necessary to provide legal grounds for protecting young girls from FGM.
  4. Intervention – if religious communities and the law condemn FGM, convincing individuals to relinquish the practice through sexual and reproductive health education will be a natural and more feasible next step.



[1] Jones, Susan D., Ehiri, John, and Ebere Anyanwu. “Female genital mutilation in developing countries: an agenda for public health response.” European Journal of Obstetrics & Gynecology and Reproductive Biology 116.2 (2004): 144-151. http://www.sciencedirect.com/science/article/pii/S0301211504003501

[2] Magoha, G.A. O., and O.B. Magoha. “Current Global Status of Female Genital Mutilation: A Review.” East African Medical Journal 77.5 (2000): 268-272.

[3] Jenkins, Richard A. “Religion and HIV: Implications for Research and Intervention.” Journal of Social Issues 51.2 (1995): 131-144.

[4] “Chapter 2: Organizations that help shape community health.” http://www.jblearning.com/samples/0763746347/46347_CH02_4849.pdf.

[5] Berg, Rigmor C. and Eva Denison. “A Tradition in Transition: Factors Perpetuating and Hindering the Continuance of Female Genital Mutiliation/Cutting (FGM/C) Summarized in a Systematic Review.” Health Care for Women International 10 (2012). http://www.tandfonline.com/doi/full/10.1080/07399332.2012.721417#tabModule.


Breastfeeding and HIV +

January 31st, 2013

Since we learned about HIV and AIDs and it’s effect on millions of women this past week, I thought that it would be appropriate to focus on how this disease is a major obstacle to encouraging women in developing countries to breast feed. I will then mention one possible intervention tool that may make it possible for HIV positive mothers to easily breastfeed their infant without worrying about transmitting the disease.

World-renown journals in the United States, such as Pediatrics and the Journal of Nutrition, have touted the benefits of solely feeding infants breast milk for six months (1).  Yet, breastfeeding in developed countries and developing countries is important for different reasons. For instance, many argue that breastfeeding is especially important in developing countries where malnutrition and infant deaths due to diarrhea and other preventable diseases are common. As a result, several health organizations, including UNICEF, Save the Children, and the World Health Organization (WHO) have focused on the unique needs of infants and mothers in developing countries. In 2003, WHO and Unicef published the Global Strategy for Infant and Young Child Feeding (2). This strategy says that “infants should be exclusively breastfed for the first six months of life to achieve optimal growth, development and health.” The strategy aims to publicize the importance of breastfeeding and to “increase the commitment of governments, international organizations and other concerned parties for optimal feeding practices for infants and young children” (3).

However, the Global Strategy also notes that the prevalence of HIV/AIDs in many areas, especially in Sub-Saharan Africa where over 60% of HIV-infected people are women, is an obstacle to safe breastfeeding. There are three ways that the disease can be transmitted from an HIV positive mother to a baby:

  1. During pregnancy/in utero
  2. During vaginal child birth
  3. Through breastfeeding (4)

In the United States and other wealthier countries, HIV positive women can take antiviral drugs, have a C section instead of a vaginal birth, and feed their baby using formula to drastically reduce any risk of transmitting the disease to their babies (5). Yet, in most developing countries, due to the low value placed on women’s lives, few women have access to any of these luxuries. Many women may not know that they are HIV positive until they are already pregnant or have given birth since they may rarely be tested or even visit a doctor. Moreover, antiviral drugs are expensive (in our reading they were quoted at about 400 dollars a month) and as we also read this past week, more money is usually spent on a man’s healthcare and antiviral medicine than on a women’s. Moreover, WHO states that mothers in developing countries are better off feeding their infant solely breast milk than feeding their infant formula as besides the natural strengths of breast milk, dirty water and contaminated baby bottles when using formula in developing countries can cause many life threatening illnesses. The situation of a mother in a developing country is thus very different from one in the United States.

For mothers in developing countries, there is a delicate balance between the risk of HIV transmission to an infant via breast milk and the risk that an infant dies of malnutrition or a disease that easily could have been prevented through the natural antibiotics in breast milk. So what should an HIV positive mother in Sub-Saharan Africa do? Should she breast feed or solely feed her baby using formula? The answer to this question is confusing and misinformation and lack of education is a major challenge.


Even the World Health Organization has drastically changed its recommendations within a very short period of time. In 2010, WHO recommended in its paper Breast is always best, even for HIV-positive mothers  “that all mothers, regardless of their HIV status, practise exclusive breastfeeding – which means no other liquids or food are given – in the first six months” (6). Yet, only two years later, WHO revised its recommendation and said, “WHO recommends either to not breastfeed at all or to breastfeed while taking antiviroal medicine/feeding antiviroals to infant” (7).  Thus, the World Health Organization’s contrasting recommendations suggest that the best procedure for HIV positive mothers who do not have access to antivioral drugs is still unclear. Moreover, a recent study on mice suggests that the ingredients in breast milk may actually kill the HIV virus and prevent oral transmission. As the lead researcher explains, “”No child should ever be infected with HIV because it is breastfed. Breastfeeding provides critical nutrition and protection from other infections, especially where clean water for infant formula is scarce. Understanding how HIV is transmitted to infants and children despite the protective effects of milk will help us close this important door to the spread of AIDS” (8). Such experiments highlight the fact that we still don’t know enough about the relationship between HIV transmission and breast milk.

However, experiments have shown that currently, the use of antiretrovirals (ARVs) is one of the best ways to dramatically reduce the risk of transmission through breastfeeding. Women who took ARVs themselves during breastfeeding or gave ARVs to their nursing infant daily saw a drop in transmission from an estimated 5-20% to just 2% (9). Moreover, not only do ARVs help protect the infant from carrying the disease, but they also help ensure that women receive appropriate care for their own HIV (10).

One Intervention: Antiretrovirals Nipple Shield

Researchers at Cambridge University cleverly designed a nipple shield that women can use to breastfeed their infant and easily feed their infant ARVs. The idea is that ARVs can be put inside the shield which is placed over a mother’s breast and which the infant sucks on. In this way, the milk that the infant is receiving is already being “purged” of the HIV virus (11). A promotional video about this new invention can be found here: http://justmilk.org/media.html. However, it’s important to note that this device is still in its early design stages and has not been tested on subjects yet. Moreover, the intervention doesn’t address the problem of the high cost of ARVs. Instead, the nipple shield simply creates an easier way for mothers to feed their infants breast milk with HIV-fighting drugs. Nevertheless, I think that it’s a very creative idea and am curious to see where it goes from here.



1  http://www.childinfo.org/breastfeeding_overview.html

2)  http://whqlibdoc.who.int/publications/2007/9789241595193_eng.pdf

3) Ibid.

4) http://aids.gov/hiv-aids-basics/prevention/reduce-your-risk/pregnancy-and-childbirth/

5) Ibid.

6) http://www.who.int/bulletin/volumes/88/1/10-030110/en/index.html

7) http://www.who.int/maternal_child_adolescent/documents/9241590777/en/index.html

8)  http://www.sciencedaily.com/releases/2012/06/120614182751.htm

9) http://www.who.int/maternal_child_adolescent/documents/9241590777/en/index.html

10) Ibid.

11) http://justmilk.org/




A Look Inside Maternal Waiting Homes

January 31st, 2013

Maternal waiting homes are residential facilities built with the intent on improving access to skilled birth attendants and emergency obstetric care for women living in remote areas.  These homes are within easy reach of a hospital or health center equipped with medical supplies and trained staff that can give antenatal and emergency obstetric care. The homes are especially useful for women identified with a high-risk pregnancy as it allows them to be near life-saving services they may need. In some locations, women can access a nearby maternal waiting home up to three weeks before her expected due date. At the home traditional birth attendants will provide education on health, family planning, and breastfeeding (1). Once a woman goes into labor and should complications arise she can be promptly transported to a nearby hospital for delivery.

This concept of a maternal waiting home has been documented in the literature since the 1960s and in 1991 the World Health Organization highlighted the potential advantages of implementing these homes as a part of addressing high rates of maternal mortality in the developing world (2). Since maternal waiting homes have become a popular strategy in health systems in developing nations and have received support from large donors and the United Nations. Maternal waiting homes are based on the premise of identifying pregnancies that may result in complications. Women defined as ‘high risk’ include those expecting their first delivery, with many previous births, very young women, and older women with pre-eclampsia (high blood pressure). These homes do not require high technology and rely on resources within the community.

As maternal waiting homes are a large investment in terms of infrastructure, their efficacy is often questioned and little research has been done to assess if they increase the number of women in remote areas to use hospital services to deliver (2). There are also barriers that prevent women from using maternity waiting homes. Various barriers are listed as follows:

  • The cost of staying in a maternity waiting home may exceed costs of home delivery.
  • If homes are crowded, poorly staffed, unsafe at night, or lack water and food
  • Lack of transportation to the facility
  • Lack of respect from staff
  • Home locations may still be far from a hospital that provides emergency obstetric care.   (3)

Cost is at the top of the list of barriers preventing women from using maternity waiting homes. Women are expected to pay for their meals and make voluntary financial donations. The staff may not speak indigenous languages and some homes do not allow women to have family stay with them making them feel isolated. Traditionally many cultures have women give birth in a kneeling position so when women are brought to the hospital and required to lie down they are made uncomfortable. Strategies to make maternal waiting homes more attractive for women are to provide birthing chairs which allow women to deliver in a sitting position, providing more well equipped maternity waiting homes, developing a standardized protocol of services, providing more sexual health/prenatal education, and culturally acceptable care (4).

  1. http://www.womendeliver.org/updates/entry/celebrate-solutions-maternity-waiting-homes-in-liberia/
  2. http://www.who.int/bulletin/volumes/90/2/11-088955.pdf
  3. http://supportsummaries.org/support-summaries/show/do-maternity-waiting-homes-improve-maternal-and-neonatal-outcomes-in-low-resource-settingsa
  4. http://www.pahef.org/en/successtories/39/23-maternity-waiting-homes-.html
  5. http://www.nyasatimes.com/wp-content/uploads/2012/11/inside-the-shelter.jpg (photo)

Important data on the commercial sexual exploitation of children in Costa Rica is scarce

January 31st, 2013

Commercial sexual exploitation of children (CSEC) is a term that encompasses prostitution, sex tourism, pornography, and trafficking for sexual purposes. The literature regarding the commercial sexual exploitationof children in Costa Rica is significantly scarce. The secrecy of child sexual exploitation clearly contributes to this lack of information, but inadequate resources are also a factor [1].

The UN Convention of the Rights of the Child outlines the rights of all human beings under the age of 18 (or younger in countries where majority of age is attained earlier by law) [2]. Countries that have ratified this convention regularly appear before the Committee on the Rights of the Child to report on their latest advances in the promotion of children’s rights and their compliance with the convention [2]. In 2007, the Committee expressed concern for Costa Rica’s lack of data and research on the prevalence of commercial sexual exploitation of children and its disaggregation based on sex, age and minority status [3].

My research indicates that no comprehensive studies of commercial sexual exploitation in Costa Rica have been published since 2001. Casa Alianza (The Latin American version of Covenant House), EPCAT (End Child Prostitution, Child Pornography, and Trafficking of Children for Sexual Purposes), and the Audrey Hepburn Children Fund conducted the latest investigation [1]. The inequity in terms of CSEC research not only affects all children in Costa Rica by virtue of living in a developing nation, but also affects certain populations within the country more than others. The few data that exists has mostly been collected on children in the capital, leaving the situation of those in the rural provinces even more unexposed [1].

Tackling commercial sexual exploitation of children is urgent regardless of how many children are affected by it, but understanding the extent and intricacies of the problem is key to develop and implement effective interventions [3]. With the limited budget of the Costa Rican government and the dangers of conducting research on such a corrupt environment, it seems unlikely that the necessary studies will be conducted soon. Policy and advocacy to foster the study of CSEC in the country are needed. However, in the mean time, the data from the 2001 study can still inform measures to tackle CSEC.