HOW THE GLOBAL GAG RULE IS HARMING MATERNAL HEALTH PROGRESS IN KENYA

This article was originally published by Youth For Change, the global network of youth activists fighting gender-based violence on 

Policy decisions made in the USA can have wide reaching consequences. Kenyan SRHR advocate Alex Omari explains the devestating impact the Global Gag Rule will have on women in Kenya and across Africa...

Since 2010 and the enactment of the Constitution of Kenya, maternal health projects have been on the up, with increasing hope of finally acknowledging women and upholding their rights. Another step on the right path was the institution of National Guidelines for reducing maternal mortality and morbidity from unsafe abortion in Kenya in September 2012. On the eve of Madaraka day in 2013, His Excellency the President declared free access to maternal services in all public health facilities which was a notch higher towards realizing global development.

However, on 3rd December 2013, the then Director of Medical Services withdrew the same guidelines under unclear circumstances which caused uproar among reproductive health advocates across the nation. This marked the beginning of a rocky period for the sector, as the providers were reluctant to provide comprehensive reproductive health services.

According to a study carried out by African Population and Research Center in 2012, an estimated 464,690 induced abortions occurred in Kenya in 2012, corresponding to an induced abortion rate of 48 abortions per 1000 women of reproductive age (15-49 years), and an induced abortion ratio of 30 abortions per 100 births in 2012. These high rates and complications from unsafe procedures accelerated maternal deaths nationally.

At the global arena, the former US President’s Administration was supportive of the maternal health programs but as expected by many reproductive health advocates, the Trump administration looks to be a backlash. Truth be told, the majority of the people around the world had expected Hillary Clinton to win the US election,s and hence many were comfortable that there was to be a buy-in and continuation of the Obama Legacy. This meant that there was no contingency plan as what would be the next step in case the unforeseen happens, which indeed happened.

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What is the Global Gag rule?

Every time there is a new administration in US, there is always that critical decision on whether or not to adopt the Mexico City Policy. First announced in Mexico City in 1984 by President Reagan’s administration, the policy requires all nongovernmental organizations operating abroad to refrain from performing, advising on or endorsing pregnancy by choice initiatives if they wish to receive federal funding. To date, support for the Mexico City Policy has been strictly partisan: it was rescinded by Democratic President Bill Clinton on 22 January 1993, restored by Republican President George W Bush on 22 January 2001 and rescinded again by Democratic President Barack Obama on 23 January 2009 and again restored a few days ago by President Trump.

The Global Gag Rule or Mexico City Policy stipulates that taxpayer dollars should not be used to pay for pregnancy by choice programs or related services (such as counselling, education or training). The impact of the Policy is an increase in maternal deaths and morbidities aggravated by unsafe abortions.

This move will deny thousands of the Kenyan women access to the comprehensive reproductive health services through the Ksh. 60 billion annual grant from the US government. As of today, 220 million women from developing countries have unmet need for family planning in which Kenya is included.

Alternative avenues need to be explored for the women to have a voice in this world at this stage. Most recently the Canadian and Dutch governments have come in support for women and will fill the void left by USAID in the developing nations. More needs to be done across the globe

National Maternal Health Advancement nearing the ditch after Global Gag Rule Executive Order

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After the promulgation of the Constitution of Kenya (2010), maternal health projects saw light and there was hope of finally acknowledging women and upholding their rights. This was seen as a step in the right path after the National Guidelines for reducing maternal mortality and morbidity from unsafe abortion in Kenya were instituted in September 2012.On the eve of Madaraka day in 2013, His Excellency the President declared free access to maternal services in all public health facilities which was a notch higher towards realizing global development.

However, on 3rd December 2013, the then Director of Medical Services withdrew the same guidelines under unclear circumstances which caused uproar among reproductive health advocates nationally. This marked the beginning on the bumpy industry as the providers were reluctant to provide comprehensive reproductive health services.

According to a study carried out by African Population and Research Center in 2012, an estimated 464,690 induced abortions occurred in Kenya in 2012, corresponding to an induced abortion rate of 48 abortions per 1000 women of reproductive age (15-49 years), and an induced abortion ratio of 30 abortions per 100 births in 2012. This high rates and complications from unsafe procedures accelerated maternal deaths nationally.

At the global arena, the former US President’s Administration was supportive of the maternal health programs but as expected by many reproductive health advocates, the Trump administration was to be a backlash. Little be told that, majority of the people around the world had expected Hillary Clinton to win the US elections and hence many were comfortable that there was to be a buy-in and continuation of the Obama Legacy. This meant that there was no contingent plan as what would be the next step in case the unforeseen happens, which indeed happened.

Every time there is a new administration in US, there is always that critical decision on whether or not to adopt the Mexico City Policy. First announced in Mexico City in 1984 by President Reagan’s administration, the policy requires all nongovernmental organizations operating abroad to refrain from performing, advising on or endorsing pregnancy by choice initiatives if they wish to receive federal funding. To date, support for the Mexico City Policy has been strictly partisan: it was rescinded by Democratic President Bill Clinton on 22 January 1993, restored by Republican President George W Bush on 22 January 2001 and rescinded again by Democratic President Barack Obama on 23 January 2009 and again restored a few days ago by President Trump.

The Global Gag Rule or Mexico City Policy stipulates that taxpayer dollars should not be used to pay for pregnancy by choice programs or related services (such as counselling, education or training). The impact of the Policy is an increase in maternal deaths and morbidities aggravated by unsafe abortions. This move will deny thousands of the Kenyan Women access to the comprehensive reproductive health services through the Ksh. 60 billion annual grant from the US government. As of today, 220million women from developing countries have unmet need for family planning in which Kenya is included.

Alternative avenues need to be portrayed for the women to have a voice in this world at this stage. Most recently the Canadian and Dutch governments have come in support for women and will fill the void left by USAID in the developing nations. More needs to be done across the globe

Counties with highest burden Maternal Mortality

 

COURTESY OF UNFPA Kenya

13th August 2014

Maternal mortality is one of the indicators of reproductive health status of the population. Efforts to reduce maternal deaths have for decades been a focal point of international agreements and a priority for women’s rights and health groups throughout the world because a maternal death is one of life’s most tragic outcomes. The irony is that almost all maternal deaths are entirely preventable given proper medical surveillance and intervention.

In the last round of censuses, the United Statistics Statistical Division (UNSD) encouraged many developing countries to include questions on pregnancy related deaths as a way of helping improve on the quantity and quality of data needed in the estimation of maternal mortality in the world. This was subsequently adopted in the 2009 Kenya Population and Housing census.   Respondents were asked to report any death in the household in the last 12 months prior to enumeration. These were subsequently named the recent deaths in the household.  Among the deceased females age 12 to 49 subsequent questions were asked on whether the female deaths were pregnancy related (i.e. during pregnancy, during delivery or within two months after delivery).

Measurement of maternal mortality

Several indicators are used to measure maternal mortality in order to display sources of different risks as well as interventions. In the first place, all maternal deaths as outcomes from pregnancy and the first definition ispregnancy-related death which is the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the cause of death.  When information on the cause of death is available, then we have maternal death, which is the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes.

However, for comparison purposes between different contexts due to differences in the risk of pregnancy maternal mortality ratio (MMR) are often used. Maternal mortality ratio (MMR) is thus the number of maternal deaths during a given time period per 100,000 live births during the same time period. MMR captures the risk of death in a single pregnancy or a single live birth or in technical terms it measures the extent of obstetric risk.

In the entire country, a total of about 32,021 women of reproductive age were reported to have died out of which 6,632 died of pregnancy related causes. Out of the total number of women of reproductive age who had died, 21 percent was as a result of pregnancy related causes. Table 1 shows the ranking of top 15 counties by number of maternal deaths and maternal mortality ratio. Columns 1-3 are the ranks by number of   maternal deaths. It indicates that only 15 out of 47 counties account for 98.7 % of the total maternal deaths in the country. However, the number of deaths masks important considerations such as the size of women population in the region as well as the frequency of pregnancies, an alternative ranking is by maternal mortality ratio which takes into account the obstetric risk. This is provided from column 4 to 6. Mandera and Wajir still rank highest in terms of absolute number of maternal deaths as well as the increased obstetric risks.

 

TABLE 1: RANKING OF COUNTIES BY NUMBER OF MATERNAL DEATHS AND MATERNAL MORTALITY RATIO

Rank Region maternal deaths Rank Region Maternal mortality ratio (deaths per 100,000 live birth
KENYA 6,623 KENYA 495
1 MANDERA 2,136 1 MANDERA 3795
2 WAJIR 581 2 WAJIR 1683
3 NAIROBI 533 3 TURKANA 1594
4 NAKURU 444 4 MARSABIT 1127
5 KAKAMEGA 364 5 ISIOLO 790
6 KILIFI 289 6 SIAYA 691
7 NANDI 266 7 LAMU 676
8 BUNGOMA 266 8 MIGORI 673
9 HOMABAY 262 9 GARISSA 646
10 MIGORI 257 10 TAITATAVETA 603
11 KISUMU 249 11 KISUMU 597
12 SIAYA 246 12 HOMABAY 583
13 TRANSNZOIA 234 13 VIHIGA 531
14 GARISSA 208 14 SAMBURU 472
15 KWALE 203 15 WESTPOKOT 434
Other counties 85
Total 6,538
Percent of the total number of deaths 98.7

 

Although Nairobi, Nakuru, Kakamega, Kilifi, Nandi Bungoma, and Kwale rank higher in terms of number deaths, in terms of MMR they do not rank higher. In terms of the maternal mortality burden it is therefore important to include risks in number of deaths as well as obstetric risk. This is shown in Table 2. At national level nearly half of deaths (48 %) occur during delivery. In 5 counties (Lamu, Garissa, wajir, Mandera and Turkana) over half of deaths occur during delivery. The county with highest proportion dying during pregnancy is Marsabit. Siaya, Kisumu and Taita taveta have the highest proportion dying in the post-partum period. The implication here is that different factors influence the risk of maternal death in the different counties. Kenya is among the top 10 Countries with the highest number of HIV-associated maternal deaths and about 20 percent of maternal deaths is indirectly related to HIV. Thus HIV may be important in Nyanza region counties which have the highest prevalence of HIV while other factors may be important in Mandera, Wajir and Garissa with low prevalence of HIV.

 

TABLE 2: RANKING OF COUNTIES BY BURDEN OF MATERNAL MORTALITY

County Maternal deaths MMR Percent of deaths during
Pregnancy Delivery 2 months after delivery
Mandera 2,136 3795 28 56 16
Turkana 175 1594 24 54 22
Wajir 581 1683 28 60 12
Migori 257 673 24 45 30
Nakuru 444 374 28 40 31
Siaya 246 691 22 28 50
Kisumu 249 597 18 33 48
Nairobi 533 212 25 38 38
Homa Bay 262 583 22 34 43
Kakamega 364 316 20 44 36
Garissa 208 646 25 61 13
Marsabit 97 1127 30 47 23
TaitaTaveta 129 603 16 36 48
Isiolo 32 790 25 56 19
Lamu 52 676 10 65 25
Kenya 6,623 495 26 48 26

– See more at: http://kenya.unfpa.org/news/counties-highest-burden-maternal-mortality#sthash.tt7GUS3y.dpuf

New WHO guidelines to improve care for millions living with female genital mutilation

Courtesy of WHO

News Release

New WHO recommendations aim to help health workers provide better care to the more than 200 million girls and women worldwide living with female genital mutilation.

Female genital mutilation (FGM) describes all procedures that involve the partial or total removal of external genitalia or other injury to the female genital organs for non-medical reasons. FGM has no health benefits, can cause grave harm, and violates the rights of girls and women. Procedures can cause severe bleeding, problems urinating, and later cysts, infections, and death. FGM can also result in complications in childbirth and increased risk of newborn deaths.

International migration has now made the practice, prevalent in 30 countries in Africa and in a few countries in Asia and the Middle East, a global health issue.

The need for health care

Health workers across the world now need to be prepared to provide care to girls and women who have undergone FGM. But, health workers are often unaware of the many negative health consequences of FGM and many remain inadequately trained to recognize and treat them properly. As a result, many women may suffer needlessly from physical and mental health consequences due to FGM.

“Health workers have a crucial role in helping address this global health issue. They must know how to recognize and tackle health complications of FGM,” says Dr Flavia Bustreo, WHO Assistant Director General. “Access to the right information and good training can help prevent new cases and ensure that the millions of women who have undergone FGM get the help they need.”

Since 1997, there have been growing international efforts to stop FGM. These include research, work within communities, revised legal frameworks and growing political support to end the practice, as well as international monitoring bodies and resolutions that condemn it. In 2007, the United Nations Population Fund (UNFPA) and the United Nations Children’s Fund (UNICEF) initiated the Joint Programme on Female Genital Mutilation/Cutting to accelerate the abandonment of the practice.

The WHO guidelines build and contribute to these efforts, underlining the recognition that action must be taken across sectors to stop the practice and help those who are living with its consequences.

The recommendations focus on preventing and treating obstetric complications; treatment for depression and anxiety disorders; attention to female sexual health such as counselling, and the provision of information and education.

The guidelines also warn against the so called “medicalization” of FGM, for example when parents ask health providers to conduct FGM because they think it will be less harmful.

“It is critical that health workers do not themselves unwittingly perpetuate this harmful practice,” adds Dr Lale Say, WHO Coordinator, Department of Reproductive Health and Research at WHO.

Global strategy to stop health-care providers from performing female genital mutilation

In 2010, WHO published a “Global strategy to stop health-care providers from performing female genital mutilation” in collaboration with the UNFPA and UNICEF Joint Programme on Female Genital Mutilation/Cutting and other partners.

One fundamental measure to prevent medicalization of FGM is the creation of protocols, manuals and guidelines for health providers. These include what to do when faced with requests from parents or family members to perform FGM on girls, or requests from women to perform re-infibulation after delivery.

The guidelines also highlight the need for more research to improve evidence-based practice, so that health workers can better manage the complications arising from FGM, and the health community is better informed about the associated health risks, which also can contribute to effectively work towards the elimination of this harmful practice.

Note to editors:

Recommendations include:

  • de-infibulation to prevent and treat obstetric complications, as well as to facilitate childbirth, and prevent and treat problems with the urinary tract system;
  • mental health including cognitive behavioural therapy and psychological support to treat depression and anxiety disorders;
  • female sexual health covering sexual counselling to prevent or treat female sexual dysfunction;
  • information and education for all women and girls who have undergone female genital mutilation, and health education and information on de-infibulation, where appropriate, for both health-care providers and for women and girls.

http://www.who.int/mediacentre/news/releases/2016/female-genital-mutilation-guidelines/en/

The Painful Knife

fgm

 

By Alex Omari

Female Genital Mutilation has been a cultural practice for some of the Kenyan communities over decades but it’s time we all stood up and said “No to FGM”. Despite it being illegal, some people still practice it privately. In 2011, Kenya banned female genital mutilation by passing a law to make it illegal to practice FGM or to take someone abroad to be ‘cut’ famously known as the “ Prohibition of FGM Act”. Faith, a 10 year old girl (not her real name) told me of her story of how she went through the terrible ordeal of going through the knife.
‘‘When I closed school for the December holidays, I was told by my mum that we are to visit our aunt for the festive season. My aunt and my mum had planned it all leaving me in darkness .When we were at my auntie’s place; I was told that I would remain behind as mum left. After that, a strange woman visited our house and that’s when the aunt said that I was going to be a big girl ’’

FGM is very painful, traumatizes girls and results in numerous negative health consequences that last for ages and can even cause death. This is a form of violence against girls that oppresses them and hence prevents the girls from fully participating in the nation’s progress.

Over 140 million girls and women globally, are estimated to have undergone some form of FGM. Currently, more than three million girls, majority being below 15 years of age, undergo the procedure each year. The just released recent Kenya Demographic Health Survey (KDHS, 2014) indicates that 21 percent of women reported to being circumcised, as compared with 27 percent in 2008-09 and 32 percent in 2003.
Research shows that FGM is practiced by different ethnic within the country in different ways. It is far more prevalent among the Somali (93.6percent), Kisii (84.4 percent) and Maasai (77.9 percent) communities.

From the survey data, Kenya achieved an annual rate of reduction of 6 percent in the prevalence of FGM between 2008 and 2014. FGM has both immediate and long-term effects on women’s health and these include severe bleeding, infection, shock and recurrent urinary tract infections.

The current statistics indicate that we are heading towards the right direction though much needs to be done if we are to realize vision 2030 developmental goals. This can only be achieved if we have uncompromising leadership and political will supported by on toes law enforcement and effective community mobilization. The social norm change practice should be felt at the community level.

https://twitter.com/alexomari1

Teenage Pregnancy Burden

#Teenagers should be Listening to  School Bells Ring NOT Wedding Bells!!!!

By Alex Omari

tenage-pregnancy

Reproductive health concerns of adolescents have received increasing international attention in recent years. Early childbearing is linked to a number of undesirable health outcomes such as risk of death, pregnancy-related illnesses, abortion, infertility and exposure to sexually transmitted diseases including human immunodeficiency virus/acquired immunodeficiency syndrome . Female adolescents, compared to their male counterparts, face disproportionate health concerns due to teenage pregnancies.

Although sexual activity among the adolescents is widespread around the world, the determinants and consequences are likely to vary from one region to another. Early pregnancies are more pronounced in Sub-Saharan African (SSA) countries, most of which experience high levels of poverty. Due to the differences in socio-economic as well as cultural backgrounds, the results from a developing country like Kenya are likely to differ from those based on experiences of the richer, industrialized nations. For instance, given limited resources in rural areas, girls are forced to drop out of school or get married at an early age. In addition, inability to meet basic and personal material needs makes teenage girls susceptible to pre-marital sex. Such factors are likely to predispose them to unwanted pregnancies.

In Kenya, teenage pregnancy is not only as a reproductive health issue, but is also a multi facet issue as it directly affects the current and future socio-economic well-being of women. Early childbearing deny girls the opportunity to complete education and the ability to acquire human capital skills which are critical in the labour market. Given the absence of welfare benefits and child support, teenage pregnancies lead to increased dependency, and are likely to perpetuate poverty and low status of women. The relatively high levels of poverty and with the HIV/AIDS pandemic being toll order among the Kenyan youth, teenage pregnancies pose a serious policy problem.

Even though teenage pregnancies are viewed as one of the major hindrances to girl’s education in Kenya, there has been little effort in critically evaluating the underlying determinants. And by the fact that interest in fertility studies and policies has largely focused on adults, less attention has being accorded to adolescents.

Despite its implications, empirical studies on causes of teenage pregnancies in the context of
African countries are scanty. More often, teenage pregnancy is mentioned merely as one of the consequences of the high-risk sexual behavior

https://twitter.com/alexomari1