Sexuality and women's rights in armed conflict in Sri Lanka

The discourse of human rights in armed conflict situations is well adapted to respond to violence and violation, invoking internationally agreed principles of civil and political rights. However, in areas where the subject or domain of rights discourse is contested or controversial, human rights advocates appear less prepared to promote and defend such rights. Sexuality is one such domain. This paper explores the complex sexual choices women in Sri Lanka have had to negotiate, particularly widows and sex workers, within a context of ethnic conflict, militarisation and war. It argues that sexuality cannot be defined exclusively in terms of violation, even in a context dominated by violence, and that the sexual ordering of society may be subverted in such conditions. Newly widowed women and sex workers have had to negotiate self-determination as well as take responsibility for earning income and heading households, in spite of contrary community pressures. For women, political and economic rights are closely linked with the ability to determine their sexual and reproductive choices. The challenge to women's and human rights advocates is how to articulate sexual autonomy as a necessary right on a par with others, and strategise to secure this right during armed conflict and postwar reconstruction.     

Abortion as empowerment: reproductive rights activism in a legally restricted context

Background

This paper analyzes the strategies used by activist health professionals in Argentina who justify providing abortion despite legal restrictions on the procedure. These “insider activists” make a case for abortion rights by linking pregnancy termination to a woman’s ability to exert agency at a key point in her reproductive life, and argue that refusing women access to the procedure constitutes a grievous health risk. This argument frames pregnancy termination as an issue of empowerment and also as a medical necessity.

Methods

This article is based on ethnographic research conducted in Argentina in 2013 and 2015, which includes in-depth interviews with abortion activists and health professionals and ethnographic observation at activist events and in clinics.

Results

During the period of my field research, the medical staff in one clinic shifted from abortion counseling, based on a harm reduction model, to legal pregnancy termination, a new mode of abortion provision where they directly provided abortions based on the legal health exception. These insider activists formalized the latter approach by creating a diagnostic instrument that frames women’s “bio-psycho-social” reasons for wishing to terminate a pregnancy as medically justified.

Conclusions

The clinical practice analyzed in this article raises important questions about the potential for health professionals to take on an activist role by making safe abortion accessible, even in a context where the procedure is highly restricted.

     

Misoprostol and the politics of abortion in Sri Lanka

Misoprostol, a WHO essential medicine indicated for labour induction, management of miscarriage and post-partum haemorrhage, as well as for induced abortion and treatment of post-abortion complications, came up for registration in Sri Lanka in December 2010. The decision on registration was postponed, indefinitely. This has wide-ranging implications, as misoprostol is widely available and used, including by health professionals in Sri Lanka, without guidance or training in its use. This paper attempts to situate the failure to register misoprostol within the broader context of unsafe abortion, drawing on data from interviews with physicians and health policymakers in Sri Lanka. It demonstrates how personal opposition to abortion infiltrates policy decisions and prevents the issue of unsafe abortion being resolved. Any move to reform abortion law and policy in Sri Lanka will require a concerted effort, spearheaded by civil society. Women and communities affected by the consequences of unsafe abortion need to be involved in these efforts. Regardless of the law, women will access abortion services if they need them, and providers will provide them. Decriminalizing abortion and registering abortion medications will make provision of abortion services safer, less expensive and more equitable.     

Maternal mortality due to cardiac disease in Sri Lanka

Objective

To investigate Sri Lankan maternal deaths due to heart disease and to consider low-cost interventions to reduce these deaths.

Methods

A qualitative study based on retrospective audit of all maternal deaths and late maternal deaths in Sri Lanka caused by cardiac disease in 2004.

Results

A total of 145 maternal deaths were recorded in 2004, for a maternal mortality rate of 38 per 100 000. There were 42 indirect deaths, 25 of which were due to cardiac disease; 23 deaths had a specific cardiac cause listed. Standard care was identified in prepregnancy counseling, contraception, and prenatal community and specialist care.

Conclusion

Cardiac disease is a major cause of maternal mortality in Sri Lanka, second only to postpartum hemorrhage. Rheumatic mitral valve disease is responsible for more than a third of maternal deaths from cardiac disease. Substandard care was identified in all cases; strategies to improve care could allow a reduction in maternal cardiac deaths.     

Pulmonary metastases from cervical cancer in Sri Lanka.

Cervical cancer is the second commonest malignancy in Sri Lankan women. The records of 2075 patients treated for cervical cancer from 1989 to 1993 were reviewed. Thirty-eight patients (1.8%) developed pulmonary lesions consistent with metastases. The median age at the time of presentation with metastases was 49.8 (range 24-73) years. Ten patients (26.3%) had pulmonary metastases at presentation. Twenty-eight (73.7%) developed metastases during follow-up. By the end of 2 years 27 (96.4%) of these patients had developed pulmonary metastases. The median time from diagnosis of cervical cancer to the detection of pulmonary metastases was 9 months. The commonest histological cell type was the large cell non-keratinising squamous carcinoma. Nine (23.7%) of these patients were asymptomatic. Two patients had lung metastases on initial staging chest X-ray while the other seven were detected during routine 3-monthly surveillance chest X-rays as follow up of primary treatment. This emphasises the importance of incorporating routine surveillance chest X-ray as part of the regular follow up. All patients with pulmonary metastases had abnormal shadows in chest X-rays. Nodular lesions were the commonest radiological findings. Local disease was controlled in 17 (55.3%) of the patients who developed metastases during follow-up, while 11 (28.9%) had active disease. There were 24 patients with spread to other sites at the time of diagnosis of pulmonary metastases. The discovery of effective chemotherapy agents is anticipated.     

Reproductive health concerns in six conflict-affected areas of Sri Lanka

This article draws on a study conducted by the Women and Media Collective between 2004 and 2005 to highlight some of the reproductive health concerns of women from Sinhalese, Tamil and Muslim ethnic groups, living in situations of conflict in Sri Lanka. The study focussed on women from six conflict-affected areas in the north and east of the country: Jaffna (Northern Province), Mannar and Puttalam (North-Western Province), Polonnaruwa (North-Central Province), Batticaloa and Ampara (Eastern Province). Higher levels of poverty, higher rates of school drop-out, low pay and precarious access to work, mainly in the informal sector, higher rates of early marriage, pregnancy and home births, higher levels of maternal mortality and lower levels of contraceptive use were found. Economic, social and physical insecurity were key to these phenomena. Physically and psychologically, women were at high risk of sexual and physical violence, mainly from their partners/spouses but also from family members, often related to dowry. The article brings out the voices of women whose lives have been overshadowed by conflict and displacement, and the nature of structural barriers that impede their right to health care services, to make informed decisions about their lives and to live free of familial violence.     

Achieving Millennium Development Goals 4 and 5 in Sri Lanka

Sri Lanka has an exemplary record in maternal and child health care. Provision of free education for over 60 years has helped to empower women. Medical care is accessible and provided free of charge. The maternal mortality ratio and the other indices of maternal and neonatal health have shown uninterrupted improvement since 1930. Midwives and the policy to increase their presence has been the key to success. Public health midwives provide care at the doorstep. Institutional midwives carry out the vast majority of deliveries, of which 99% occur in hospitals. Although on target with the Millennium Development Goals, some challenges that still remain are maternal death from postpartum haemorrhage and unsafe abortion, and perinatal deaths due to congenital abnormalities and prematurity.     

Distribution of human papillomavirus genotypes in archival cervical tissue from women with cervical cancer in urban Sri Lanka

Objective

To identify the contributions of various human papillomavirus (HPV) genotypes in tissue samples from women diagnosed with cervical cancer in Sri Lanka.

Methods

In a retrospective study, archival cervical tissues samples (n = 108) obtained from Sri Lankan women diagnosed with histologically proven invasive squamous cell carcinoma between 2006 and 2007 were tested for HPV. Genotyping of HPV DNA was performed using an INNO-LiPA assay.

Results

Overall, 93% of tumor samples tested positive for HPV DNA. HPV types 16 and 18 accounted collectively for 83.4% of the positive samples.

Conclusion

The findings suggest that the HPV genotypes responsible for causing cervical cancer in Sri Lanka are similar to those reported elsewhere worldwide. Consequently, women in Sri Lanka could benefit from currently available prophylactic HPV vaccines should they be implemented.     

Neonatal mortality in Sri Lanka: Timing,causes and distribution

Abstract

Objective.?To evaluate the timing, causes and distribution of neonatal deaths in Sri Lanka, to provide information for policy makers, to undertake appropriate measures to achieve the Millennium Development Goals.

Methods.?All neonatal deaths, reported to the Registrar General's Office, Sri Lanka, from 1997 to 2001, were included in the analysis.

Results.?During this 5-year period, 17,946 neonatal deaths have occurred, of them 90.5% have occurred during the first week of life. The leading causes were preterm deliveries (33.2%), infections (19.8%) and cardiac anomalies (17.4%). The neonatal mortality rates (NMR) were higher in districts with specialised neonatal care facilities and high concentration of estates.

Conclusions.?Approximately 3600 neonates die in Sri Lanka annually, even though it has a lower NMR compared to rest of the South Asia. Neonatal deaths were higher in the major cities and in the estate sector. The majority of neonatal deaths were due to complications of preterm birth, neonatal sepsis and cardiac anomalies.     

Safe motherhood in Sri Lanka: a 100-year march.

The present safe motherhood status in Sri Lanka has been achieved by a series of activities for health and social development during the past century. While ancient and traditional religious, as well as cultural concepts provided a sound foundation, it was the policies that focused on human development that resulted in reducing the maternal mortality rate to 2.4 per 10000 live births, and the infant mortality rate to 16.5 per (1000) live births. Maternal and Child Health (MCH) services were initially closely linked to improvements in the healthcare infrastructure and social development, while family planning introduced in 1953 enhanced its progress further. With MCH integrated into reproductive health, the march towards a safer motherhood in Sri Lanka will require the implementation of new policies and strategies.     

Scoping Review of Baby-Friendly Hospital Initiative Compliance and Breastfeeding Initiation in Sri Lanka

ObjectiveTo synthesize the evidence for associations between Baby-Friendly Hospital Initiative (BFHI) compliance and breastfeeding initiation in Sri Lanka.Data SourcesWe searched PubMed, ProQuest, Scopus, Embase, MEDLINE, and CINAHL using various Boolean operators for multiple search terms. Studies conducted in Sri Lankan published in English from April 1, 2000, to April 30, 2020 were considered. We also searched Sri Lankan government and international organization websites and hand-searched reference lists of the included documents.Study SelectionWe screened the titles and abstracts of 99 records and retrieved 31 documents for review and assessment. We selected 24 documents, including the full texts of primary research articles, reviews, discussions, letters to the editor, and government reports if they specifically addressed breastfeeding initiation and BFHI compliance in Sri Lanka.Data ExtractionWe extracted the data for author(s), year of publication, study setting, study design, aims of the study, population and sample size, inclusion and exclusion criteria, data collection methods, participant response rate, prevalence, associated factors of breastfeeding initiation, and BFHI compliance and its contributing factors if they were available depending on the type of document.Data SynthesisWe synthesized the data narratively to address the research questions. We identified contradicting reports of the prevalence of breastfeeding initiation (23.5%–100%) across Sri Lankan hospitals. Breastfeeding initiation was significantly associated with mode of birth. We identified inconsistent compliance with the BFHI, and poor compliance was associated with inadequate staff training and ineffective monitoring systems.ConclusionWe found inadequate evidence to clarify the association between BFHI compliance and breastfeeding initiation in Sri Lanka. It is therefore not possible to conclude whether adherence to Baby-Friendly care is optimizing breastfeeding initiation in Sri Lanka.     

Sexual rights and gender roles in a religious context

A common feature of the five faiths discussed in this article is change over time. This allowed diversity within the religions, and generally led to a degree of liberalization, but in some faiths or their sects, resulted in a narrow or rigid interpretation. For example, the golden Vedic Period of Hinduism in India when “women were worshipped” gradually faded, ushering in the social evils of female feticide, child marriage, and “sati.” The advent of Islam in the seventh century banned female infanticide, but has been unable to abolish many tribal pre-Islamic customs such as female genital mutilation in Africa and “honor killings” in parts of Asia. On the other hand, in China, the inferior status of women accorded by Confucianism has been rectified to a large extent by legislation; this has, however, been offset by a restrictive population policy allowing only one child or two children per couple in some areas of the country (with no limit in Tibet), which has led millions of women to resort to prenatal sex diagnosis and abortion if the fetus is female. In the West, the debate over the use of biomedical technology continues, with various rabbinic rulings permitting the use of assisted reproductive technologies by Jews to fulfill the obligation to procreate, and the Vatican reinforcing its opposition to these and to genetic testing on embryos and embryonic stem cell research.     

Morbidity and mortality associated with pre-eclampsia at two tertiary care hospitals in Sri Lanka

AIM: To report the occurrence of morbidity and mortality associated with carefully phenotyped pre-eclampsia in a sample of nulliparous Sinhalese women with strictly defined disease. METHODS: A phenotyping database of 180 nulliparous women with pre-eclampsia and 180 nulliparous normotensive pregnant women who were recruited for a study into genetics of pre-eclampsia was analyzed. RESULTS: Women who developed pre-eclampsia had significantly higher systolic blood pressure (SBP; P = 0.002) and diastolic blood pressure (DBP; P = 0.002) at booking (at approximately 13 weeks of gestation). 38.3%, 28.3% and 33.3% of women delivered at <34 weeks, at 34-36 weeks, and at term, respectively. 78% required a cesarean section. Complications included SBP > or = 160 mmHg (75.5%); DBP > or = 110 mmHg (83.8%); proteinuria > or =3 + (150 mg/dL) in the urine protein heat coagulation test (87%); renal failure requiring dialysis (2%); platelet counts <100 x 10(9)/L (13%); > or =70 U/L in aspartate and/or alanine aminotransaminase (15%); placental abruption (4%); eclampsia (9%); and one maternal death. Maternal complications indicative of severe disease, apart from the incidence of SBP > or = 160 mmHg and DBP > or = 110 mmHg, were not significantly different in early and late-onset pre-eclampsia; fetal outcome was better with late-onset disease. 48% of babies were small for gestational age. Only 80 of 135 babies of women with pre-eclampsia whose condition could be confirmed at 6 weeks post-partum were alive. CONCLUSIONS: Pre-eclampsia in Sinhalese women is associated with severe maternal morbidity and fetal morbidity and mortality, suggesting that modification of the Western diagnostic criteria and/or guidelines for medical care may be necessary. There is an urgent need to improve neonatal intensive care services in Sri Lanka.     

Effect of training for care providers on practice of essential newborn care in hospitals in Sri Lanka

OBJECTIVE: To evaluate the effectiveness of a training program for care providers in improving practice of essential newborn care in obstetric units. DESIGN: Before-and-after study with an intervention and a control group. SETTING: Five hospitals in the Puttalam district in Sri Lanka. PARTICIPANTS: Eight hundred and ninety-two mother-newborn pairs (446 before and 446 three months after). INTERVENTION: A 4-day training program on essential newborn care for doctors, nurses, and midwives of the obstetric units in two hospitals. MAIN OUTCOME MEASURES: By direct observation, practices of essential newborn care at delivery in the labor room on a subsample. By interviewing mothers, immediate skin-to-skin contact and early initiation of breastfeeding. From health records, "undesirable health events" of the newborns. RESULTS: Practices of cleanliness, thermal protection, and neonatal assessment improved significantly in the intervention group. The intervention was effective in improving skin-to-skin contact by 1.5 times and early initiation of breastfeeding by 3.4 times. Undesirable health events declined from 32 to 21 per 223 newborns in the intervention group and from 20 to 17 per 223 newborns in the control group. CONCLUSION: A comprehensive 4-day training program can be followed by a significant improvement in essential newborn care practices in obstetric units.     

Abortion in a restrictive legal context: the views of obstetrician-gynaecologists in Buenos Aires,Argentina

In Argentina, unsafe abortions are the primary cause of maternal mortality, accounting for 32% of maternal deaths. During reform of the National Constitution in 1994, the women's movement effectively resisted the reactionary government/church position on abortion. Health professionals, including obstetrician-gynaecologists, played conflicting roles in this debate. This article presents results from a study carried out in 1998-1999 of the views of 467 obstetrician-gynaecologists from public hospitals in Buenos Aires and its Metropolitan Area, focus group discussions with 60 of them, and interviews with heads of department from 36 of the hospitals. The great majority believed abortion was a serious public health issue; that physicians should provide abortions which are not illegal; that abortion should not be penalized to save the woman's life, or in cases of rape or fetal malformations; and that women having illegal abortions and abortion providers should not be imprisoned. Some 40% thought abortion should not be penalized if it is a woman's autonomous decision. Those who were better disposed towards the de-penalization of abortion cited a combination of public health reasons and the need for social equity. The women's health and rights movement should do advocacy work with this professional community on women's needs and rights, given the prominent role they play in reproductive health care provision and in the public sphere.     

Sexual and bodily rights as human rights in the Middle East and North Africa

A regional workshop on sexual and bodily rights as human rights in the Middle East and North Africa was held in Malta in 2003, attended by 22 NGO representatives from Jordan, Egypt, Lebanon, Palestine, Tunisia, Morocco, Algeria, Turkey, Pakistan and USA. The meeting aimed to develop strategies for overcoming human rights violations in the region with reference to law and social and political practices. Session topics included sexuality and gender identity; sexuality and sexual health; sexuality and comparative penal law; sexual rights in international documents; advocacy and lobbying. Sexual rights, sexual health and education, sexual violence and adolescent sexuality were explored in depth, including taboos and emerging trends. Specific areas of concern included marital rape, early marriages, temporary marriages, sexual orientation, premarital and extramarital sexuality, honour crimes, female genital mutilation, unmarried mothers, adolescent sexuality, unwanted pregnancies and safe abortion, sexuality in education and health services. An analysis of civil codes, penal codes and personal status codes indicated a clear imperative for legal reform. Participants heard about efforts to promote the right to sexual orientation which have already been initiated in Lebanon, Turkey and Tunisia. Networking within the region and with counterparts in other regions in comparable situations and conditions was deemed essential.     

Intimate partner violence against women in the capital province of Sri Lanka: prevalence, risk factors, and help seeking

This article presents findings from a cross-sectional community survey exploring intimate partner violence (IPV) against women in the Western province of Sri Lanka. Findings show that lifetime prevalence of physical violence (34%), controlling behavior (30%), and emotional abuse (19%) was high and the prevalence of sexual violence was low (5%). Young women and those with partners who abused alcohol/drugs and had extra-marital affairs are at increased risk of violence. Although living in a patriarchal society, low prevalence of child marriages and lack of dowry-related violence could be to Sri Lankan women's advantage relative to their Asian counterparts in preventing IPV.