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Memo to the United Nations Women

March 11th, 2011

TO: The United Nations Women

FROM: Amelia Herrera

RE: Women’s Access to Contraception in the Middle East

My name is Amelia Herrera, and I am writing to you concerning an issue that has a significant impact on the safety and well-being of women today in the Middle East. Many countries in the Middle East are struggling to either reduce or maintain their current population growth rate. Outside of Africa, countries in the Middle East have some of the highest fertility rates in the world: Afghanistan has a rate of 5.39, the Gaza strip has a rate of 4.74, in Yemen the rate is 4.63, and the rate in Iraq is 3.67.[1] According to the United Nations Population Fund, The ability for women to plan how many children they have and when they have them is a recognized basic human right, and access to contraceptives save millions of infant lives every year, reduce poverty, slow population growth, and stabilize the environment as well as economy.[2]

The Middle East is a diverse region that encompasses many different cultures, traditions, economies, political structures, and religions. However, many countries in the Middle East consist of populations predominantly practicing Islam. This presents a distinct challenge in that under Sharia law, the sacred law of the Islamic faith, women are not given the same rights and roles as men, although it is made clear in the Qur’an that they are deemed to be equal. The way that these laws are realized differ from country to country, but in many cases they present significant challenges to women, especially in accessing contraception. In  the UAE, physicians are required to have consent of the spouse in order to prescribe women contraception.[3] In Saudi Arabia, women are often required the escort of a male guardian to even enter a hospital, depending on the belief system of the hospital administrator.[4]

There are Middle Eastern countries that have had successful reductions in fertility rate in the past decade or so. This includes Iran, which has implemented a large scale media campaign by the Ministry of Islamic Culture and Guidance that raised awareness of population issues in Iran and promoted family planning services. This in turn effectively reduced the fertility rate from 3.2% in 1986 to 1.2% in 2001, one of the fastest drops ever recorded in history.[5] While many governments have expressed that they are taking efforts to reduce birth rates, few are contributing significant financial resources to make sure that this is indeed the case. Not until countries commit financially will there be any real change for women, who are putting their health and the health of their children in danger through ineffective family planning access.

[1] https://www.cia.gov/library/publications/the-world-factbook/rankorder/2127rank.html?countryName=Iran&countryCode=ir&regionCode=me&rank=146#ir

[2] http://www.unfpa.org/rh/planning/mediakit/docs/new_docs/sheet1-english.pdf

[3] http://secretdubai.blogspot.com/2009/03/lie-back-and-think-of-abu-dhabi.html

[4] http://www.hrw.org/en/node/62251/section/6

[5] http://www.earth-policy.org/index.php?/plan_b_updates/2001/update4ss

Memo: Echoing Colombian Sexual Healthy Policy in the Rest of Latin America

March 8th, 2011


To: Hilary Clinton, Secretary of State

From: Director of the WHA/PPC (Western Hemisphere Affairs Office of Policy Planning and Coordination)

Subject: Birth control dissemination/Family Planning in Latin America—Colombia’s New Policies as Example

Background: Contraception Policy in Latin America

Family Planning is essential to women’s health, and it has been shown to lead to reduction of poverty and more desirable family situations for women. Thus, both children and women  have more control over their future and livelihoods. Family an rights and economic factors, it is within U.S. interest to further these rights.

Women with pre-child-bearing opportunities and ultimately fewer children sizes can contribute to the Latin American economies and thus assist stability. This is most apparent in their control over timing of childbirths: with access to contraception, they can better decide time in their life they are willing to rear children, how many they can afford, and how far apart between ages they can logically handle. Studies also show that smaller families allow people to attend school longer (see figure 1) and both mothers and children can eventually achieve better economic stability.

But as part of the goal to increase funding for preventative contraceptive needs of Latin American women, it will be necessary to exclude important messages on other related topics—such as address abortion debate, competing needs such as maternal care and HIV treatment, and goals of gender equality/women empowerment (Wilson).

Why Latin America?

The Millennium Development goals and UNFPA are both doing great work in family planning right now; however, they are focusing on selected countries in sub-Saharan Africa and South Asia (USAID, International). The world is turning away from Latin America for family planning because it has a smaller population and thus a less total need than Asia and Africa (see figure 2). Also, many assume that as our neighbors and our backyard, Latin America will receive the U.S. government’s focus when we pass our individual appropriation bills for Family Planning.  It is time to take on that expectation and help the women of Latin America, spread prosperity across the Americas—furthering human rights and improving Western Hemisphere economic stability.

Current Funding Situation:

Most U.S. funding for family planning is procured through two main sources: Congress’s annual appropriations bills, and money funneled through USAID (Kaiser). U.S. funding for international family planning has fluctuated and decreased as a share of the U.S. global health budget. After reaching approximately $575 million in 1995, it dropped or remained relatively flat for more than a decade, until this year when it reached $648.5 million, including $525 million in the USAID account. The request next year, the 2011 fiscal year budget, is $715.7 million for family planning (see figure 3).

Two years ago, on January 23, 2009, just after President Obama had repealed the Mexico City Policy—which had gagged vital birth control organizations from receiving government funding, you, Madam Secretary, said that you were looking forward “to promote programs and policies that ensure women and girls have full access to health information and services” (CRS). I wholeheartedly support your commitment, and I hope that over the next few years this can include our Latin American neighbors. Now that the President has proposed to increase the funding to $715 million for 2011—which is the highest funding for this issue in US history (USAID, Obama)—it needs to be followed through on with a newfound focus on our nearest neighbors. The budget cuts have been necessarily harsh across the board, but this is one are worth investment: never before has birth control been so affordable and effective.

There so much to be gained without a relatively small actual monetary investment. The costs include the contraceptive commodities themselves (condoms, IUDs, pills), personnel, and management/shipping. And given the proximity of Latin America, the shipping costs are minimal. But these costs are not to be borne by the U.S. alone; the most efficient and culturally sensitive distribution would be through lobbying the NGOs and governments of the nations themselves to follow the Colombian method.

The Colombian Method:

Historical Background: Sexuality and Contraception in Colombia

From the introduction of contraceptives in Colombia during the 1960s up until present, the nation’s population growth rate has “decreased steadily.” And during an especially key period between 1980 and 1995, the population growth rate decreased by an estimated 23% (IES). For example, the average children born per family moved from seven during the 1960s to just under three in 2001. Yet, there are wide variances between regions; for example, the average in 4.3 in the mountainous regions. Similarly, education levels play an important role–such as the average of five children per woman among those lacking any formal education, compared to 1.8 for women with higher education (IES).

Another important factor is culture. Colombia has an interesting mix of cultures which contribute to its sense of sexuality in society: “The Spanish cultural influence, which is a mix between the Arab-Andaluzian influences, mixes the glorification of sensuality and eroticism in its most beautiful form with the Spanish Catholic Inquisition’s very strong repressive ideas.” To confuse matters worse, the African culture adds a view of “sexuality, eroticism, and sexual vigor as natural phenomena” (IES).

Then, one other incredibly important aspect of cultural norms is religion. Studies in Colombia have shown “the presence of important religious beliefs related to sexuality”: the ingrained Catholic ideas around birth control and pleasure, including “religious concepts that emphasize feminine resignation” contribute significantly to sexuality in Colombia (IES). Luckily, despite the fact that a majority of Colombians are Catholic, social and economic issues as well as marital instability “have led to the acknowledgment of the civil rights of all couples and their children.” According to studies and censuses, more than half of Columbians continue to practice Catholicism, but also engage in birth control without experiencing guilt: 72.2 percent of women in a relationship use birth control of some form. Yet, the issue is still not equitable among the genders: for every six women using contraception in the late 1990s, only one man did so (IES).

On the other hand, Colombia has for over a decade had several laws which seek to protect the rights of women: “Family Planning is viewed as an individual’s right and an obligation of the state.” In the 1991 Constitution, all discrimination against women in condemned in Articles 17 through 30. The Constitution states: “Women have civil rights as they pertain to reproduction and the judicial system equal to men in education, nationality, employment, health, matrimony and family.” While such legislation was a good step forward, however, implementation has often occurred rarely if at all (IES).

As with much of the world, premarital sex is common throughout Colombia. Studies have shown 90.4 percent of males and 62.8 percent of females have engaged in premarital sex before college life (IES). And in the realm of adolescents, ten percent of 13-14 year olds has had sexual relations, and in increases to forty percent for 15-17 year olds (IES).

Colombia’s 2010 Policy:

The nation’s policy is such a fundamental success that even this early on, I think it is clear already that we should encourage other Latin American countries to emulate.”Since a law was passed guaranteeing all citizens access to free birth control drugs and procedures, clinics have opened, especially in impoverished areas where teen pregnancy rates are high” (Kraul).

Free contraceptive implants were given out in December 2010 as part of “one of Latin America’s most liberal reproductive rights laws,” passed by Colombia’s Congress which guarantees citizens access to free contraception in the form of medicinal or surgical methods. Psychologist Maribel Murillo of the Diamante health clinic in Colombia notes that “it will advance the sexual rights of women of little means, many of whom already have several children” (Kraul).

One factor that applies to the rest of Latin America is the concept of Colombia as a mostly- Catholic nation (estimates are around 90%). And yet, legislation as progressive as this was able to advance reproductive rights “in this largely Roman Catholic nation.” Colombia has been slowly liberalizing, evidenced by the constitutional court rulings just before this policy on removing abortion penalties for medical providers (Kraul).

Enabling women to access reproductive health care for free, the Colombian policies are making women’s control over their futures and bodies a priority. Beyond social justice, this legislation also certainly presents economic benefits for the nation: “because maternity and neonatal care are among the healthcare system’s fastest-growing costs, free contraceptive medicine and surgeries could end up saving the government money” (Kraul).

As observed in various studies, teen pregnancies cause a vicious poverty cycle. And given Colombia’s worsening situation in this area (2010 figures show that 21% of teen Colombian girls bear children—compared to 13% in 1990).  In the rest of Latin America, this 2010 teen pregnancy rate in Colombia was surpassed only by Nicaragua (which was up to 25%), and Venezuela, El Salvador, and Honduras (all at around  21.5%). If we compare them to ourselves, the U.S. is estimated by Guttmacher to have around  a 7% of teen pregnancy rate. As a response to the Colombia’s teen pregnancy issues, another result of the policy was the creation of over 600 offices have been opened across Colombia to increased access to contraception and advice for adolescents, called Friendly Health Services for Youths (Kraul).

Applying the Lessons to the Rest of Latin America:

If these liberal social service policies can radiate across the region, the issues of teen/unplanned pregnancy, HIV/AIDS, and STI infections could be easily controlled. Of course, the exact plan cannot apply universally. As we know from even the variance among U.S. states and reproductive health policy, small demographic and social/political changes can have a large impact on the logistics of family planning policies. Each country had its own background, political climate, and specific needs.


Works Cited:

CRS. <http://pdf.usaid.gov/pdf_docs/PCAAB323.pdf>

IES. José Manuel González, M.A.; Rubén Ardila, Ph.D.; Pedro Guerrero, M.D.; Gloria Penagos, M.D.; and Bernardo Useche, Ph.D. “Colombia,” from International Encyclopedia of Sexuality, Volume I-IV 1997-2001, Edited by Robert T. Francoeur. <http://www2.hu-berlin.de/sexology/IES/colombia.html#2>

Kaiser Family Foundation. “US Government and International Family Planning & Reproductive Health.” US Global Health Policy Fact Sheet.

Kraul, Chris. “Colombia launches large-scale birth control effort,” 12 December 2010, Los Angeles Times. <http://articles.latimes.com/2010/dec/12/world/la-fg-colombia-birth-control-20101212>

USAID, “International Alliance For Reproductive, Maternal, and Newborn Health.” <http://www.usaid.gov/our_work/global_health/pop/alliance.html>

USAID, “Obama Administration Statements on Family Planning.”  <http://www.usaid.gov/our_work/global_health/pop/news/obama_fp.html >

Wilson Center < http://www.wilsoncenter.org/events/docs/Gillespie.pdf>

Birth Induction: A Message to the AMA

March 3rd, 2011

To the American Medical Association:
I write to you today to express my concern with the hyper-medicalization of maternal care in American hospitals and clinics.
I note with great disappointment that the US has come 41st in a 2010 Amnesty International ranking of maternal death rates around the world.  [1] One of the major influences here might be the rise in medical interventions in childbirth, including inductions, epidurals, episiotomies, and c-sections. Of course these are often necessary steps to save lives, and I absolutely advocate them in these cases. However, I find it hard to believe that the 32 women out of every hundred who give birth by cesarean in the US really needed it. Given that the risk of death following a c-section is three times as high as for a vaginal birth [2], I think this is a serious cause for concern and could be correlated with our maternal death rates.

According to a Congressional Budget Office paper from 2008, “Newer, more expensive diagnostic or therapeutic services are sometimes used in cases in which older, cheaper alternatives could offer comparable outcomes for patients. And expensive services that are known to be highly effective in some patients are occasionally used for other patients for whom clinical benefits have not been rigorously demonstrated.”
This is a pattern which seems especially strong in childbirth. The appropriate use of technology can be tricky in a process which is entirely natural yet can be quite life-threatening. But we must avoid relying so heavily on our safety measures that they become unsafe when inappropriately used.
Therefore, I urge you to take action to reduce doctors’ reliance on medical technology when it is unnecessary, and instead foster caring, personal interactions between birthing patients and caregivers. I would like to specifically address labor inductions, because they are often the first link in a chain of unnecessary technological interventions. But, I believe this is only one of many aspects of modern childbirth that needs re-evaluation in the medical community.

The rate of labor inductions has doubled since 1990, [4] although there has been no change in the size of babies, length of pregnancies, or incidence of maternal illnesses requiring inductions. The induction drugs Pitocin and artificial prostaglandin are known to cause more intense contractions, which can interfere with the flow of oxygen-rich blood to the fetus. This can result in fetal distress, associated with passage of meconium (fetal excrement) and breathing difficulties at birth as the baby inhales its excrement. Induction also results in higher rates of caesareans. [3]
For the mother, artificial induction is associated with increased postpartum blood loss and increased uterine rupture (though it is still rare). It also makes labor a whole lot more painful, often necessitating an epidural for pain relief. And an epidural can stop labor altogether. [5] Voilà! The case for another cesarian.
I really encourage you to educate doctors on these impacts. For women where induction is not warranted, I recommend increasing fetal monitoring in the late weeks of pregnancy to make sure there is no distress, and encouraging the trial of “older, cheaper alternatives” for induction: breast stimulation, castor oil, sweeping the membranes (which encourages the production of natural prostaglandins in the cervix), and even, yes, sexual intercourse– because semen is the most concentrated source of natural, harmless, prostaglandin! Researchers have found cervical mucus prostaglandin levels 10 to 50 times higher than normal after pregnant women had intercourse. [6]

I understand that pregnancy can have increased risks beyond 42 weeks, and do not advocate refraining from induction when there is clear evidence of fetal distress, placental calcification, or other indicated maternal diseases. However, I think that medical caregivers need to recognize that induction can be just as dangerous as the risk they are trying to reduce, if it is not truly warranted in their patients. Rather than relying on such procedures, I think it important for doctors or nurse-midwives to be in better communication with their patients, monitoring them regularly and discussing their options thoroughly throughout the pregnancy. I recommend that you require doctors in your association to meet more often with women who have surpassed their due date, but allow the pregnancy to continue normally. I ask that you require hospitals to do a better job of reviewing induction justifications, and bring educational programs on the associated risks to institutions where the rates seem unnecessarily high.

I think that this could really help create a safer, saner system of childbirth for mothers in America, and ultimately the resulting reduction in procedures could also save us quite a bit of healthcare spending. Win-win!

1. http://www.guardian.co.uk/world/2010/mar/12/amnesty-us-maternal-mortality-rates
2. http://en.wikipedia.org/wiki/Caesarean_section
3. Gaskin, Ina May. Ina May’s Guide to Childbirth. New York: Bantam, 2003. Print.
4. http://www.acog.org/from_home/publications/press_releases/nr07-21-09.cfm

Also consulted:

The Anti-Human Trafficking and Juvenile Protection Department in Cambodian National Police under the Ministry of the Interior

March 3rd, 2011

The Anti-Human Trafficking and Juvenile Protection Department in Cambodian National Police under the Ministry of the Interior

To Whom It May Concern:

As a concerned citizen of the world, I would like to bring your attention to the plight of Cambodian girls and women who are forced into the sex trade. As you may be aware, 1 in 40 girls in your country will be sold into the sex trade. I have spent the past nine weeks researching sex trafficking in Cambodia, and hope to share with you my findings, and propose an intervention to rehabilitate the girls and women, so that they may be healthy, productive and contributing members of society. The goal of my research and this policy memo are to address the questions:

1. How can we most effectively rehabilitate these girls and women? How can we empower them to raise strong and healthy children who are the future of Cambodia?

2. How can we prevent the sexual exploitation of future generations of females?

Who We Need to Help:

Sex workers are not just teenage girls – we see women of all ages, and girls as young as infants being exploited by brothel owners and pimps. Paying for sex is a fundamental violation of human rights: the right of a woman to her own body, dignity, and freedom. In addition to violating her at the time of sale and for the duration of time in which she is enslaved, sexual exploitation affects a woman’s entire future. If she contracts a sexually-transmitted-infection or suffers severe physical or psychological injuries during her time in a brothel, she will be unable to raise healthy and productive children, who can contribute to Cambodia’s workforce and future as a nation.

Effective Rehabilitation:

I propose that the Ministry of the Interior model a national program after that of Somaly Mam. Somaly is more than a survivor of sex slavery- she’s a human rights crusader, saving girls from brothels and giving them a new life. Her organization is unique because it employs doctors, social workers, and former victims to teach the girls and women at her centers about AIDS prevention, sexual health, emotional health, women’s rights, and the joys of living freely and independently. “Being a former victim myself, I know exactly what their needs are. What they need most is love and understanding,” she explains. Rehabilitation will be most effective if it combines health professionals with strong female mentors who are survivors of sex trafficking or prostitution themselves. This way, girls are less likely to feel intimidated or judged by the people trying to help them.

  • Goal: Provide girls and women with the skills to reintegrate into society and the courage and self-esteem to reduce their risk of falling back into the sex trade.
  • Approach: “All of our programs share an emphasis on the collective voice of the survivors, who participate in every aspect of our work. Survivors who have gone through our rescue, rehabilitation, and reintegration programs can choose to join our Voices for Change initiative, which offers them the opportunity”  to do outreach and teach classes to other survivors. VFC members visit brothels, distributing condoms and doing HIV/AIDS education. Girls in the program learn how to speak, read, and write English, use computers, and learn trades. They’re also given time for creative expression and reflection.

There are so many psychological consequences of prostitution, torture, rape, and physical violence that absolutely stay with the girls for the rest of their lives. We want to minimize the long-term negative consequences of theses traumatic experiences, so that we will have a healthy and capable workforce, strong families, and a just social system and culture of equality and prosperity. Girls who are living in the Somaly Mam Foundation/AFESIP centers undergo intense post-traumatic stress and grief counseling with social workers and doctors. Rescued children and women cannot just be released back into the world, but need counseling, medical care, education, and support to learn to live independently. This transition to the real world must be done in a safe and nurturing environment, because many escaped sex slaves are paranoid of the world around them, untrusting of all men, and have such low self-confidence that they don’t realize they can make decisions for themselves about their bodies and their lives. In order for a rehabilitation center to be effective, it must be in a safe, protected location. It is important that we allocate enough resources to hire security for the facility, as there have been problems with pimps breaking into centers and stealing their girls back.

Structural Change:

Around the world, sex trafficking and sex slavery are a huge issue. Cambodia is not alone. It’s important to help the survivors, if we want to produce a more productive and sustainable workforce in sectors that do not violate human rights.  The Ministry of Social Affairs, Labor, Vocational Training and Youth Rehabilitation (MOSALVY)’s efforts to eradicate the sex trade are commendable, and I urge you to work towards more of these programs for the benefit of all sectors of society. I was thrilled to learn that the Ministry of Women’s and Veteran’s Affairs and MOSALVY collaborates with UNICEF’s Community-Based Child Protection Network, to teach young community members about the hazards of trafficking, so that individuals are equipped with the tools to recognize potential victims and help them. It is wonderful that MOSLAVY operates two shelters and works to place survivors with NGOs for long-term recovery. I hope that by learning from the Somaly Mam/AFESIP model, the Ministry of the Interior can expand upon its efforts to end sexual exploitation by thoroughly training its staff, expanding its community outreach to both address and prevent these issues, and creating new and improved rehabilitation facilities.  Ideally, we could prevent this before it happens by helping families rise out of extreme poverty without selling their daughters into the sex trade.

Cultural Change:

I believe that Cambodia can benefit from adopting the spirit of Eve Ensler’s V-Day campaign and commitment to ending all forms of violence and silencing of women. Ensler’s “V-girls” global network of activists and advocates is about letting girls embrace their unique energy, compassion, passion, and vibrant joie de vivre to make change. “What changes things is people. People becoming emotional creatures. What’s changing the Congo is people speaking up. if we’re not awake in our emotional creatures, we can’t wake up others,” says Ensler. Cambodia has thousands of girls with strong voices who are being silenced, numbed, buried. If we empower these girls to use their spark to create the change they imagine for this world, we will see a revolution led for the girls of the sex trade, by the girls themselves. What women want and need in a rehabilitation center is a place to heal, a place to be trained to heal others, and a place to gather their strength. We need to use dance, theater, music, art, and writing to harness the energy of girls, and help them rise out of trauma and subjugation. I understand that resources are limited, but may I suggest that we provide every single Cambodian girl who is rescued from a brothel with a copy of Eve Ensler’s “I am an Emotional Creature,” a collection of monologues inspired by girls around the world, about their experiences in and with sex slavery, forced labor, FGM, body image, and the emotional rollercoaster of life. Ensler proves that the written word is tremendously empowering and inspiring of creativity, activism, and lasting grassroots change.

Preventative Measures:

The Human Rights Task Force on Cambodia, an international NGO set up by five Asian and one American human rights organizations, believes that women may be sold into the sex trade by family members, but if they ever escape, they face immense discrimination, isolation, and stigmatization by relatives and friends. We must realize that a woman permanently bears the ‘mark’ of a sex slave, and may be completely abandoned by her former support network. Furthermore, her marriage prospects are significantly diminished, so starting a new life and finding employment and a romantic partner may seem and be impossible. This contributes to the heavy shame that women bear, both during their time in brothels, and once they leave. If we do not do something to eliminate this paralyzing social stigma, we will lose a generation of Cambodians, because their moms will be uneducated, and living in poverty, without the support of their community and government.

In addition to being ostracized, a woman’s physical and psychological health are damaged, sometimes beyond repair. For girls and women who contract HIV/AIDS and other dangerous STIs, as well as those whose psychological distress escalates into severe depression or suicidal thinking, actually leaving the brothel doesn’t have any benefits. Physical “freedom” or distance from the brothel, pimps, and clients doesn’t equal immunity, protection, or an erasure of cumulative damage. If a woman gets pregnant through intercourse with a brothel client, she risks giving birth to an unhealthy baby, or one with HIV. Because of the severity of mother-to-child transmission of this disease, we need to make an effort to make medical services available to these women.

What can the government’s rehabilitation centers do to promote family support of survivors?

  • Offer multi-faceted support (sort of like family therapy) for girls and women who have escaped from the sex trade, or better yet, do it preventatively, in schools and community centers. Teach families that sex slaves are not to blame for the spread of HIV/AIDS, survivors of rape and sexual abuse are not unworthy or impure, having sex with virgins does not cure a man of AIDS, and all women deserve respect, dignity, and the protection of their human rights.
  • Make parents and siblings of survivors a big part of the support network post-rescue. Perhaps holding gatherings to allow parents to voice their concerns, support each other, and learn to accept, respect, and love their daughters, celebrating their strength.

I hope that through collaboration with local and international NGOs, the Ministry of the Interior can expand its efforts to rescue girls and women from the sex trade, and rehabilitate them so that they are empowered, productive members of society. Through dedication to ending the human rights violations of sex trafficking and slavery, we can create a more equal, peaceful, just, and cohesive nation that will thrive economically, socially, and politically.

Thank you for your consideration.

In good health,

Elise Geithner

Stanford University Undergraduate


Bureau of East Asian and Pacific Affairs. “Cambodia: Prostitution and Sex Trafficking.” US Department of State. 23 July 2010. Web. 20 Jan. 2011. <http://www.state.gov/r/pa/ei/bgn/2732.htm>.

Ensler, Eve. “I am an Emotional Creature.” Presentation at Castelleja School, Palo Alto, CA. 3 March 2011.

Hansen, Chris. “Children For Sale.” MSNBC. 9 Jan. 2005. Web. 2 Feb. 2011. <http://www.msnbc.msn.com/id/4038249/ns/dateline.nbc

HumanTrafficking.org. “Cambodia.”  http://www.humantrafficking.org/organizations/42

3 March 2011.

Human Rights Task Force on Cambodia. “Cambodia: Prostitution and Sex Trafficking.” Human Rights Solidarity. 13 Aug. 2001. Web. 20 Jan. 2011. <hrsolidarity.net>.

Murray, Anne. “From Outrage to Courage.”

The Road to Traffik. Prod. Norman J. Roy. The Somaly Mam Foundation. Web. 12 Jan. 2011. <www.somaly.org>.

Nair, Sowmia. “Child Sex Tourism.” US Department of Justice. Web. 20 Feb. 2011. <http://www.justice.gov/criminal/ceos/sextour.html>.

Refocus on Local Needs in Maternal Health

March 3rd, 2011

To: The MacArthur Foundation.

Title: Refocus on local needs and distribution challenges in order to magnify impact of existing tools to combat maternal mortality

The persistence of high rates of maternal mortality despite considerable technological advancements underscores the need for a shift in policy focus away from developing new technologies to improving the distribution and implementation of existing tools. While new technologies will undoubtedly continue to offer new life-saving possibilities in the field of maternal health, our current systems for identifying where and how to leverage these technologies is failing. Addressing these implementation challenges represents the most pressing need in maternal mortality reduction efforts today.

Although the proximal causes of maternal death – factors like postpartum hemorrhage and eclampsia – are similarly across most regions, the underlying barriers to life-saving care are extremely varied.  Because of this reality, there is no one-size-fits-all solution for reducing maternal mortality.  In some regions, such as in parts of rural Bangladesh, cultural beliefs regarding the cause of postpartum bleeding play a significant role in preventing women from seeking emergency obstetric care[i]. In such situations, community education programs that take up the issue of cultural beliefs may be crucially important. Elsewhere however, cultural beliefs do not pose a significant challenge to maternal care, but financial or transportation barriers are substantial.  Such differences in local contexts imply the need for diverse plans and tools to reduce maternal mortality.

Importantly, efforts to develop new technologies and systems for reducing maternal mortality have succeeded in developing strategies to address a tremendous diversity of factors related to maternal mortality. Tested tools in maternal health span a broad spectrum, ranging from community financing schemes to modified partograms[ii] to pharmaceutical interventions such as misoprostol. Still other strategies respond to more unique needs, leveraging dance and song to offer educational messages. The global attention focused around maternal health has contributed to a wealth of options for tackling the challenges of labor and delivery in the developing world. Enacted with local support, in areas where they address a defined need, these tools have the potential to effect significant reductions in the maternal mortality rate.

Unfortunately, while many effective technologies and systems to reduce maternal mortality have been identified, most of these tools remain dramatically underleveraged. For example, despite being demonstrated highly effective at halting postpartum hemorrhage, misoprostol is not widely approved for obstetric and gynecological purposes. Furthermore, even in countries where misoprostol is approved, it is often not available in the rural settings where it is most needed. Similarly disappointing distribution patterns are seen with a number of other tools for reducing maternal mortality, including financing schemes and community education programs. Until better systems are developed to increase the use of these effective tools, their potential will remain unrealized and maternal mortality will remain a significant problem.

In devising strategies to expand the distribution of tools for reducing maternal deaths, developing an understanding of local needs is critical. In order to maximize the impact of dollars directed towards improving maternal health, efforts to improve distribution of critical tools must focus on improving access to the tools capable of making the largest difference. To do this, organizations like the MacArthur Foundation need to focus their attention on developing local contacts capable of indentifying which tools would be best suited to different local contexts.

Fortunately, many areas already have local authorities on obstetric needs who could serve as valuable partners for international development organizations. Community midwives, traditional birth attendants, and local medical professions offer crucial sources of untapped knowledge and potential. While many programs offer obstetric training to these individuals, few actively solicit their input on the types of tools and systems that are needed where they work. New efforts are needed in order to make sure that community health workers are aware of different possible strategies for reducing maternal mortality and have a forum in which they can push for implementation of the tools most appropriate to their region.

The benefits of investing in partnerships with local birth attendants extend beyond new opportunities to identify local needs. These individuals offer an important source of man power that can be used to implement new tools. Efforts to make misoprostol available at the community-level, while still in their infancy, have found that community health workers, including midwives and traditional birth attendants, are capable of safely administering life-saving therapy using this drug[iii]. Efforts to task shift to para-medical health workers expands the network of individuals capable of assisting in efforts to distribute needed technologies, and can as a result significantly impact health outcomes.

While much is known about the potential impact of community health workers, new programs and research initiative are needed to better understand how to develop effective partnerships with these individuals. This is an area in which the MacArthur foundation could make a significant contribution to efforts to reduce maternal mortality. To date, programs working with community health workers have largely focuses on providing training to these individuals. While our knowledge of effective training tools has grown significantly over the past decade, our ability to develop effective two-way communication with these individuals lags behind. Our failure to establish this communication limits our ability to provide targeted solutions, designed with the needs of the communities in mind.

Technological deficits are no longer the primary obstacles to improving maternal health. The technology to save the lives of millions of women exists. What remains unknown is how the necessary tools and ideas can be delivered to the women who need it most. In light of this pressing need, the MacArthur foundation should redirect the focus of its maternal health programs to focus on promoting innovative strategies for developing strong local partnerships.

[i] Sibley et al. “Cultural Theories of Postpartum Bleeding in Matlab, Bangladesh: Implications for Community Health

Intervention.” Journal of Health, Population and Nutrition. June 2009. pp 379-390

[ii] See: “The Paperless Partogram: A simplified tool to prevent prolonged labor.” Maternova. <<http://maternova.net/blog/paperless-partogram-simplified-tool-prevent-prolonged-labor>>

[iii] Barnet et al. “Community Interventions for maternal and perinatal health.” BJOG. Vol 112. Sepember 2005. pp. 1170-1173.

Feminism, Fathers and Childbirth

February 25th, 2011

When I found an article in the New York Times by psychologist Keith Ablow [1] about how men felt less attracted to their wives after witnessing their childbirth, I realized I had not yet examined the role of male partners in women’s birthing. Of course there are alternative family structures, such as in lesbian partnerships or women who are single mothers from the very beginning. But in this blog post I would like to focus on the role that a male partner can play in a woman’s  intra- and post-partum well being.

In other cultures, there is often more of an emphasis on the whole family’s role of support for new mothers and mothers-to-be. Mukta, the doctorate student who spoke with us a few weeks ago, told me that a woman will usually return to live with her family for a few months before and after giving birth, which can be a great mechanism for protecting these especially vulnerable women from abuse or violence.
But in the US, where families tend to have a more nuclear structure, women will depend more heavily on their partner to care for and tend to them during and after the birthing. But the article from the New York Times showed an unsettling pattern. Dr. Ablow’s patient recalled witnessing the infant emerge from his wife’s vagina, and said, “how are you supposed to go from seeing that to wanting to be with…?” he stopped, implying the rest of the sentence with a nervous look in his eyes.
Dr. Ablow ascribes this discomfort with witnessing childbirth to “trouble seeing women as sexual beings after seeing them make babies.” As one blogger puts it, “for some, the erotic depends on maintaining a distinction between the sexual and the reproductive.” [2]  Rather than decrying a culture which allows men to imagine their partners as uniquely “sexual beings”, Dr. Ablow is rather sympathetic towards these men. “I myself recall feeling as if the clinical focus on childbirth during prenatal classes, including the detailed descriptions of the placenta and the meconium, took away from the wonder of the process, rather than adding to it,” he says.
Of course childbirth is messy and potentially disgusting. And it’s true that in much of the world, and in the US until the latter half of the 20th century, almost all women gave birth without their husbands, whether in the delivery room or in the arms of their female companions. But I still think that the culture of childbirth needs to adjust better to a new model of the family. In a society where the mothers and aunts and sisters are not usually present to support a laboring woman, I don’t think it is fair to advocate exonerating men who don’t want to witness their children’s birth. Because it is not a matter of “witnessing.” It is usually also a matter of actively supporting, whether physically or emotionally. I think the man’s role, if skillfully enacted, can be just as important as that of a doula or labor assistant.
If a woman requests that her husband be present with her during birth and he refuses or does so unwillingly, it is, in my opinion, far more detrimental to a relationship than the potential of a loss in libido. A woman who is abandoned by her partner in an incredibly vulnerable state, as I see it, has far more to lose. Because trust is, in the end, a bigger deal than libido.
On the other hand, an interesting article by gynecologist Michel Odent [3] provides a different (and in my opinion stronger) argument against the presence of men in the delivery room. “It is only 35 years since men first entered the delivery room, yet we have welcomed them in without question,” he says. Their eagerness to “participate,” “share the experience,” and put on a calm front for their partner’s sake in spite of their anxiety can actually really disturb a woman. “It has been proven,” he says, “that it is physically impossible to be in a complete state of relaxation if there is an individual standing next to you who is tense and full of adrenaline.” And it is well known that adrenaline inhibits the release of oxytocin, the hormone that promotes contractions and activates the mammary glands. Thus, Odent advocates that ideally women would give birth almost entirely alone, with only the help of a trusted female midwife or doula. “At the present time, when birth is more difficult and longer than ever, when more women need drugs or Caesareans,” he says, “we have to dare to smash the limits of political correctness and ask whether men should really be present at birth.”

Looking at these different perspectives has not left me with a good, conclusive sense of what a man’s role in childbirth should be. I am interested to hear your opinion. Should men be present in the labor ward? How can we help men be a truly supportive presence in the delivery room, rather than one that is awkwardly “trying to be helpful?”  And what might be done to remedy the disturbingly frequent incidence of partnerships disintegrating shortly after labor due to “loss of attraction” in men?

1. http://www.nytimes.com/2005/08/23/health/23case.html?_r=1
2. http://www.slate.com/id/2125227/

Perpetual Minors

February 24th, 2011

Even if you go to a hospital for an operation, you need a guardian. It’s your life. Why do you need his signature?”

-Riyadh, a Saudi woman

Saudi Arabia chose to ratify the UN Convention on the Elimination of all Forms of Discrimination against Women (CEDAW), however actual practices throughout the country are not necessarily in line with the legislation. Women are still treated as second class citizens, or more appropriately, as “perpetual minors”, as Human Rights Watch refers to the in their 2008 report. Saudi Arabia has a long tradition of practicing a system of guardianship, where men are required to grant permission and escort women to daily activities, such as going to the bank, airport, and hospital. “If a [pregnant] woman comes in to the hospital with a guardian, then she can leave with anyone, even the driver. If she comes in without a guardian, it becomes a “police case,” and she’ll need a guardian to come to the hospital in order for her to get discharged. She stays here if no one picks her up.”[1] This requirement is not only inconvenient and frustrating for women, but can be dangerous if husbands, fathers, or brothers refuse to take their wives to seek medical care.

One of the reservations that Saudi Arabia established when they ratified CEDAW stated that “In case of contradiction between any term of the Convention and the norms of islamic law, the Kingdom is not under obligation to observe the contradictory terms of the Convention.”[2] Although the government continually denies that the practice of guardianship is required by Islamic law, reports from various parties confirm that it is indeed widely required for many activities. “The Saudi government is saying one thing to the Human Rights Council in Geneva but doing another thing inside the kingdom. It needs to stop requiring adult women to seek permission from men, not just pretend to stop it.” [3] Guardianship requirements vary from hospital to hospital, as there are no formal regulations. What the final decision usually comes down to are the religious views of the facility administrator. According to the head of the General Directorate of Hospitals, “The law is written and clear that a woman has the right to be admitted without permission. It is the right of any lady or male to be admitted and discharged if [they are] over 18. Any procedure can be signed by the patient himself if they are wise enough. It is well known that a physician must provide medical care whenever a patient needs it. But a lot of social factors play a role limiting the application of the law. What we need right now is to work hard to educate the people about their rights. The law is there; that it is not applied is something else.”[4]

This allows an upper hand for men in negotiations of family planning, to say the least. In 2008, the total fertility rate was 5.7 children per woman, and only 32% of married women 15-49 used any contraceptive method- the number was even lower (21%) in rural areas.[5] Contraception is only legally available to married couples[6], and (semi)permanent forms, such as IUDs and sterilization, are most often the decision of the husband because of the practice of guardianship. In order for the government to really improve the lives of women, drastic steps need to be taken so that the legislation they have created in order to ensure women’s health care is not contingent upon the beliefs of health care providers.

[1] http://www.hrw.org/en/news/2009/07/08/saudi-arabia-women-s-rights-promises-broken

[2] http://www.un.org/womenwatch/daw/cedaw/reservations-country.htm

[3] see footnote 1

[4] http://www.hrw.org/en/node/62251/section/6

[5] http://www.prb.org/pdf/WomensReproHealth_Eng.pdf

[6] http://www.emro.who.int/rhrn/countryprofiles_saa.htm

“WENNA! I heard you can get it from toilets!” Debunking HIV/AIDS myths in Botswana

February 24th, 2011

In 2005 there was much media attention over the rapes of virgin girls in South Africa because sangomas (witchdoctors) were telling HIV-positive men that sleeping with virgins cured HIV. There were also reports that Tanzanian albinos were being abducted and killed in order for sangomas to extract their blood for “HIV cures.” Although there have been tremendous efforts to provide correct information to the public, misinformation is still a significant problem in the fights against HIV/AIDS.  

Botswana is no different. In a country where the government is putting millions of dollars into HIV/AIDS prevention material, Batswana still accept myths that jeopardize the efforts of prevention programs. What types of myths are present in Botswana? This question was the subject of Edward Murandu and Mkabi Chamme’s research on condom use in Botswana. Murandu and Chamme handed out 1349 questionnaires to a randomly selected group of Batswana (ranging from the age of 15 o 60). The questionnaires posed questions regarding attitudes towards condom use and unexpectedly the questionnaires indicated a high level of misinformation about HIV/AIDS. In their research Marandu and Chamme found that only 44% of the population over 15 utilized condoms.

Here is a collection of the myths that still exist in Botswana:

1)      The air from a previous toilet user can infect he next immediate user of the toilet.

2)      AIDS is caused by witchcraft and condoms cannot help to reduce the spread.

3)      “Makwerekwere” brought HIV/AIDS to Botswana. The word Makwerekwere is a derogatory term used to refer to indigenous Africans other than Tswana speakers.

4)      HIV infects only promiscuous people and prostitutes.

5)      Some traditional doctors can cure AIDS.

6)      AIDS is punishment from God, nobody can stop it.

7)      A mosquito can transmit HIV in the same way it does malaria.

In breaking down these myths, addressing witchcraft and religious beliefs are particularly important because these actors/beliefs render condom usage useless. However it is clear that these assertions are false and that condoms have proven to the one of the most effective methods of curbing the spread of AIDS (5). The Botswana government is going to have to partner with churches in order to disseminate correct information and react if these churches maintain or reinforce these myths. In addressing sangomas, this will be more difficult because Botswana has long valued traditional healers and many Batswana turn to these healers for advice and guidance.

In addition, a “substantial number of the respondents believe[d] that condoms are not effective in preventing a person from getting the virus that causes AIDS” (6). More needs to be done to educate people on the efficacy of condom use. But it’s also really important that in the education process, programs/initiatives need to stress that although condom use will lower the likelihood of HIV transmission, condom use is not 100% effective against contracting HIV. Abstinence is the only way to stay free of HIV.  It’s not about promoting one idea over another; rather it should be about presenting various perspectives so that people can make informed decisions and find methods that are the best for their circumstance.       

The misinformation about HIV/AIDS in Botswana is what led me to work with TeachAIDS. Over the summer I was the project lead on the Botswana animations and I’m happy to report that the animations are almost complete (the launch will be on March 18th!!!). What I am most proud of is the section in which we debunk the myths that exist. We’ve partnered with Botswana’s Ministry of Education and our animations will be seen by every single student (from primary to tertiary level). My hope is that our animations will correct the misinformation that’s out there and provide youth and adults to make more informed choices in the future.



A success story: CARE’s FEMME Project in Ayacucho, Peru

February 24th, 2011

Statistics raise concerns about the welfare of mothers around the world. These include: “Globally, of ten maternal deaths, eight are preventable,” and, every 52 seconds a woman dies during child birth around the world highlight the importance and need to care for women before, during, and after child birth (CARE). A great example of a possibility to improve maternal mortality in developing countries is the case of Ayacucho, a rural province in Peru, where CARE’s Foundation to Enhance Management of Maternal Emergencies (FEMME) project spearheaded an Emergency Obstetrics movement that ultimately cut maternal deaths in half. In five years, Ayacucho, a highland region in the South of Peru, went from being the second worst to one of the best provinces in terms reducing maternal mortality rates. CARE is working with the Peruvian Ministry of Health to scale up this program across the country.

As mentioned previously, Peru has an approximately 240 deaths per 100,000 live births. These ratios are higher in remote highland regions, where Ayacucho and Puno are located. After implementing CARE’s FEMME initiatives in Ayacucho, a final evaluation found that, in comparison to Puno where FEMME was not implemented, the maternal deaths were reduced by fifty percent. The percentage of women with a met-need for emergency obstetric care in Puno was only 33 percent, a number similar to Ayacucho’s before CARE’s programs were implemented.

CARE provided effective “tools, systems and structures to provided appropriate management of obstetric emergencies; in creased political will; and improved staff capacities and attitudes toward women” (CARE).

CARE’s FEMME model is based on the belief that a quality system of emergency obstetric care is a necessity if we are to save women’s lives.  Eight core strategies guide their interventions (inserted in picture diagram). In Ayacucho, FEMME focused on skilled obstetric emergencies and the promotion of a rights-based approach to health care, including respect for cultural diversity. As discussed in a previous post, cultural barriers, including prohibiting vertical birthing style and inability to speak the local dialect, prevent women from seeking care. CARE’s project made sure to support women’s decision making and cultural preferences. Women and their families were taught to recognize the warning signs of obstetric complications. Now, most health workers are knowledgeable and equipped with the skills and political support for their work. In addition, CARE trained “Vigilantes de Salud,” or citizen monitors, to build trust between health providers and people in the local community. The Vigilantes are themselves women from the community who volunteer their time to support women who are already in the hospital. Vigilantes act as cultural mediators between the patients and health providers. A trusting relationship between health provider and client is key to successful interventions.

As a result of FEMME’s success, the Peruvian Health Ministry released standard guidelines and protocols for obstetric and neonatal emergencies, largely based on those developed in the FEMME model.


CARE. A Case Study: The Impact of Maternal Health in Peru. 2007 http://www.care.org/campaigns/mothersmatter/downloads/Peru-Case-Study.pdf


[related,  cool blog about women around the world http://www.philborges.com/blog/ ]

But What About The Children: HIV/AIDS Orphans and Violence

February 24th, 2011

Reading ahead for next week’s readings on aging and elderly women’s state of living, I was reminded that HIV/AIDS and its intersections with violence against women is not merely a system of abuse and oppression that affects the women inflicted with the virus. Instead, this intersection affects family members, particularly the children often caught in the crossfire of the violence and left orphaned once their primary parent has passed away. In many of the readings, the role of elderly women in the third world acting as the primary caregivers of these children once their mothers have passed away inspired me to take a look at how children are affected by the intersection between HIV/AIDS and violence against women.

Children with parents infected with HIV/AIDS are, according to UNICEF, deprived of their first line of protection—their parents. Reasons include being separated from their parents (particularly if they work as sex workers), being kept in prolonged hospital care, and being detained in or refused educational, remand, or correctional or penal facilities as a result of their parents’ status. In addition, over 25 million children are currently orphaned by HIV/AIDS, which speaks to the far-reaching effects of the virus. (1)

Although there are studies and cases done worldwide on the ravages of AIDS and violence on children, I want to focus on a case study done in Uganda by the United Nations Study on Violence Against Children, particularly because violence against children is often committed alongside violence against their mothers. Ugands itself is a country that continues to deal with the devastating effects of the virus and the country itself has one of the highest number of children orphaned by HIV/AIDS. One of the most visible effects of the ravages of HIV has been the stigma and discrimination often ascribed to the orphans, a factor that is contributing to psychological harm, a form of abuse and violence committed against them. And while this abuse is often perpetrated by the guardians of the orphans (after their parents have died), much of the abuse happens at the hand of fellow children.

Parents are also a source of abuse and discrimination. Very often the children will get placed in the hands of fathers or aunts and uncles who perpetually abuse and discriminate against them as a result of their mothers’ death and status. This abuse most often takes the form of caning and hitting. Very often this abuse was understood “to be the guardians’ anger and frustration about having to care for the orphans when their resources were limited.” (2) Specific reasons included bed-wetting, late return home from school, and slow completion of household chores, although these were often just surface reasons meant to hide the true frustrations of the adults.

Verbal abuse was another significant method of violence against the children. Testimonies from children themselves described the abuse in detail.

“You orphan, we are suffering with you. Your mother gave us nothing; now we are stuck

with you.”

“You orphan, you are so stupid. You eat too much when you don’t dig.”

“Why do you come back late from school? You have no mother.”

“Where will you go now that your father has died of AIDS? Who will pay your school fees?”

“Your mother brought AIDS and shame to our family.”

“It’s not me who gave birth to you so why should I spend money on you?”

“You child of bad omen.”

“You are a dead body.”(3)

Lastly, the role of HIV/AIDS itself was a source of constant torment for these children, most hyper-aware of their status and its effect on themselves, their families, and their communities. Many orphans were thought or feared to have HIV/AIDS and many expressed shame that their parents had died of the disease and feared of retaliation and violence if their status was found out. Numerous research participants said that the origin of discrimination against infected orphans was the view that they were not worth caring for, since they were going to die anyway.

As one can see, violence and HIV/AIDS not only affects the women infected but their children as well. The stigma and shame associated with HIV/AIDS (part of what causes the violence aimed at infected women) likewise catalyzes violence against children, infected and otherwise. The United Nations itself has attempted to recommend possible solutions to this abuse. Some of these include:

  • assert the right of all children to protection from all forms of violence, and the need for effective human rights mechanisms and legal frameworks at international, regional and national levels

to promote and safeguard this right;

  • draw attention, through the UN General Assembly and other international, national, and sub-national mechanisms, to the scale and nature of violence against children, especially less

visible forms;

  • motivate States to fulfil their obligations to protect children and make commitments with regard to prevention, intervention and recovery related to violence against children;
  • expand and activate dynamic and effective networks and partnerships directed at the elimination of violence against children, at international, national and local levels; and
  • expand dynamic key networks and processes to support and partner with States to respond to the situation of violence against children. (4)

(1)    http://www.unicef.org/protection/index_orphans.html

(2-4) http://www.globalempowerment.org/policyadvocacy/pahome2.5.nsf/allreports/88D92CF19F341A7A8825704500251541/$file/VAC%20Uganda_web.pdf