Building coalitions to support women's health and rights in the United States: South Carolina and Florida

There is a health care crisis in the United States and women, particularly low-income women and women of colour, are paying the price. The politicisation of pregnancy, sexuality and women's reproductive rights has created a uniquely contradictory situation in many states. Policymakers are working to control women's reproductive choices and sexuality, and restricting sex education, but doing little to address the overall lack of access to quality reproductive health care. This article describes a new reproductive rights advocacy model that was implemented starting in 2003 in two US states, South Carolina and Florida. In-depth research on the status of reproductive health and rights in each state, analysed by race, economic status, county and state policy initiatives relevant to women's health, showed that in both states access to contraception and abortion, cervical and breast cancer screening and treatment, HIV/AIDS-related care and pregnancy care were poor, with African American and Hispanic women faring even worse than white women. Implementing the advocacy model involved identifying and bringing together a diverse set of health care professionals, academics and activists who formed coalitions and are now working together and developing advocacy strategies in support of policies to improve access to reproductive health care and protect reproductive rights in both states.     

Courses for medical residents and trainers in Turkey for promotion of quality of reproductive health services: a pilot study

In order to provide high quality services in reproductive health, training of health professionals is essential. In Turkey, a project for in-service training of medical residents was conducted in 2003 under the aegis of the Human Resources Development Foundation, the Turkish Ministry of Health and UNFPA. The project included a needs assessment, training programme development and evaluation activities. A seven-day course was developed to train institutional trainers in both training skills and reproductive health information. Fourteen experienced master trainers conducted four courses for 67 institutional trainers from 37 hospital departments in four cities, who in turn conducted a three-day programme on reproductive health topics in their respective institutions, using interactive teaching methods. 163 residents from departments of obstetrics and gynaecology, family medicine, urology, public health and paediatrics participated. Over three-quarters of trainers and residents who participated in the programme approved of the content of the courses. A limited number of topics, e.g. sexual health and adolescent reproductive health, were thought to need more attention. Trainers cited improvements in doctor-patient communication and quality of outpatient and in-patient care, and initiation of counselling in their institutions. We conclude that this training programme, attended by trainers and participants from different disciplines and using interactive teaching methods, has been successful as an effective training model for medical residents. The establishment of an ongoing collaboration between the Ministry of Health and other institutions involved in resident training in Turkey is needed to ensure the expansion of this programme to all residents in training.     

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 penalised 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 penalised if it is a woman's autonomous decision. Those who were better disposed towards the de-penalisation 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.     

Ten years of democracy in South Africa: documenting transformation in reproductive health policy and status

The advent of democracy in South Africa in 1994 created a unique opportunity for new lows and policies to be passed. Today, a decade later, South African reproductive health policies and the laws that underwrite them are among the most progressive and comprehensive in the world in terms of the recognition that they give to human rights, including sexual and reproductive rights. This paper documents the changes in health policy and services that have occurred, focusing particularly on key areas of sexual and reproductive health: contraception, maternal health, termination of pregnancy, cervical and breast cancer, gender-based and sexual violence, HIV/AIDS and sexually transmitted infections and infertility. Despite important advances, significant changes in women's reproductive health status are difficult to discern, given the relatively short period of time and the multitude of complex factors that influence health, especially inequalities in socio-economic and gender status. Gaps remain in the implementation of reproductive health policies and in service delivery that need to be addressed in order for meaningful improvements in women's reproductive health status to be achieved. Civil society has played a major role in securing these legislative and policy changes, and health activist groups continue to pressure the government to introduce further changes in policy and service delivery, especially in the area of HIV/AIDS.     

Yes we can! Successful examples of disallowing ‘conscientious objection’ in reproductive health care

Reproductive health care is the only field in medicine where health care professionals (HCPs) are allowed to limit a patient’s access to a legal medical treatment – usually abortion or contraception?– by citing their ‘freedom of conscience.’ However, the authors’ position is that ‘conscientious objection’ (‘CO’) in reproductive health care should be called dishonourable disobedience because it violates medical ethics and the right to lawful health care, and should therefore be disallowed. Three countries – Sweden, Finland, and Iceland – do not generally permit HCPs in the public health care system to refuse to perform a legal medical service for reasons of ‘CO’ when the service is part of their professional duties. The purpose of investigating the laws and experiences of these countries was to show that disallowing ‘CO’ is workable and beneficial. It facilitates good access to reproductive health services because it reduces barriers and delays. Other benefits include the prioritisation of evidence-based medicine, rational arguments, and democratic laws over faith-based refusals. Most notably, disallowing ‘CO’ protects women’s basic human rights, avoiding both discrimination and harms to health. Finally, holding HCPs accountable for their professional obligations to patients does not result in negative impacts. Almost all HCPs and medical students in Sweden, Finland, and Iceland who object to abortion or contraception are able to find work in another field of medicine. The key to successfully disallowing ‘CO’ is a country’s strong prior acceptance of women’s civil rights, including their right to health care.     

Working with public sector clinics to provide adolescent-friendly services in South Africa

Health care facilities can play an important role for adolescents in preventing health problems, in promoting sexual and reproductive health and in shaping positive behaviours. Extensive research has established that South African public health facilities are failing to provide adolescent-friendly health services. The National Adolescent-Friendly Clinic Initiative (NAFCI) is an accreditation programme designed to improve the quality of adolescent health services at the primary care level and strengthen the public sector's ability to respond to adolescent health needs. The key objectives of the programme are to make health services more accessible and acceptable to adolescents, establish national standards and criteria for adolescent health care in clinics throughout the country, and build the capacity of health care workers to provide quality services. One of the indicators for success of NAFCI will be increased utilisation of public sector clinics by adolescents. NAFCI is an integral component of the largest, most innovative, public health programme ever launched in South Africa, loveLife. Achieving NAFCI accreditation involves clinic self-appraisals, quality improvements, external assessments and award of achievement stars. NAFCI is currently being piloted in ten government clinics in South Africa.     

Transforming family planning programmes: Towards a framework for advancing the reproductive rights agenda

Recent international agreements call for the transformation of family planning programmes from a focus on demographic goals to the promotion of health and rights objectives. But the practical implications of this agenda for current and future programmes remain unclear. Public health resources are devoted to preventing illness and reducing the prevalence and incidence of disease across a population. Human rights methodologies focus on protecting the rights of individuals, and on the right to health and health care. Both of these approaches need to be re-thought and reconciled on a practical level to promote rights-based health programmes. Applying a rights framework to reproductive health programmes means, among other things, focusing as much on the process as on the outcome, incorporating efforts to address the gender and power dimensions of reproductive and sexual decision-making into every level of programme, and focusing on building a sense of entitlement among both the seekers and the providers of services. It also means moving beyond a focus only on the technical quality of clinic-based services to incorporate the ethos of a rights perspective at every level. Political, institutional, and technical barriers to the realisation of the reproductive health and rights agenda include national level politics, lack of capacity within civil society, and lack of transparency of institutional actors.     

Advocacy for sexual and reproductive health: The challenge in India

Six years after the Indian government affirmed its commitment to the principles of the 1994 International Conference on Population and Development, there is still a limited understanding of the concept of reproductive and sexual health among policymakers, programme managers and the public in India. Despite some progressive changes, there is a continuing focus on stabilising population growth rates and lack of unity of goals among women's rights advocates, service providers and policymakers. Advocacy efforts need to begin focusing on turning progressive reproductive health policies into concrete programmes on the ground, and continue to push for progressive policies in uncharted areas such as domestic violence. Those who implement programmes need to work with potential allies such as women's groups, development groups, health workers' associations and the media, who all need to be brought on board. What continues to be missing are policies and programmes that promote not only health but also rights and the empowerment of women. Without a strong focus on the links between these, India's reproductive health policies and programmes may become like 'grass without roots'.     

Women's groups and professional organizations in advocacy for sexual and reproductive health and rights

After the International Conference on Population and Development (ICPD) in 1994 and the Fourth World Conference on Women in 1995, sexual and reproductive health and rights (SRHR) have improved in many countries, and been supported by awareness raised by women's health advocates, increasingly by youth groups, and also by organizations of health professionals. In the HIV/AIDS area, involvement of organizations of people living with HIV/AIDS is crucial to improve prevention and care. However, after victories during the 1990s, combating opposition by social and political conservatives has taken up much energy in recent years. Continuous advocacy to broaden acceptance of the fundamental importance of SRHR, their role in meeting the Millennium Development Goals, and the imperative to increase funding, is essential.     

Making legal abortion available in Brazil: Partnership in pratice

This article describes the participation of feminist groups who work in the area of women's reproductive health and rights in campaigns for the provision of legal abortion in public hospitals in Brazil. Brazilian criminal law permits therapeutic abortion in cases where pregnancy is the result of rape orposes a serious risk to the life of the woman. Today, as a result of the combined efforts of feminists, health professionals and policymakers, more than 20 hospitals in Brazil are officially permitted to perform therapeutic abortions within the existing law. A model programme has also been developed to train service providers to do legal abortions, where the agreement of a hospital board can be obtained. This training has also improved care for illegally obtained, incomplete abortions in those hospitals but not in hospitals where doctors have not been trained. Problems with lack of access and concerns about the lack ofpublic acceptance of abortion remain. Women not only need the right to abortion but also more services and health professionals who are trained to perform abortions across the whole country.     

Sexual and reproductive health needs of sex workers: two feminist projects in Brazil

The sexual and reproductive health needs of sex workers have been neglected both in research and public health interventions, which have almost exclusively focused on STI/HIV prevention. Among the reasons for this are the condemnation, stigma and ambiguous legal status of sex work. This paper describes work carried out by two feminist NGOs in Brazil, Mulher e Saúde (MUSA) in Belo Horizonte and Coletivo Feminista Sexualidade e Saúde in S?o Paulo, to promote sexual and reproductive health for sex workers. MUSA's project "In the Battle for Health", was begun in 1992; sex workers were trained as peer educators and workshops were offered on self-care for sex workers and their clients. In S?o Paulo, the Coletivo project "Get Friendly with Her", begun in 2002, offers clinic consultations and self-care workshops on sexuality, contraception, STI/HIV prevention and self-examination. Health care needs during menstruation and unhealthy vaginal practices led to promotion of the diaphragm as a contraceptive, for prevention of reproductive tract infection and to catch menstrual blood. Meeting the sexual and reproductive health needs of sex workers depends on the promotion of their human rights, access to health care without discrimination, and attention to psychosocial health issues, alcohol and drug abuse, and violence from clients, partners, pimps and police.     

The right to love: the desire for parenthood among men living with HIV

Drug regimens and procedures now exist that will prevent parents from transmitting HIV to infants, and the ethical and legal obligation to promote and protect the reproductive rights of those living with HIV should form part of training for HIV/AIDS care and prevention. This paper reports a study that investigated issues of sexuality and reproduction with 250 Brazilian men living with HIV in S?o Paulo. We asked whether they wished to have children and whether health professionals in HIV/AIDS treatment clinics that they attended were supportive of their wishes. Health professionals were not considered by most participants to be supportive enough or even impartial about HIV-positive people having children, and paid little attention to men's fathering role. 80% of the men had sexual relationships, and 43% of them wanted children, especially those who had no children, in spite of expectations of disapproval. Few of the men received information about treatment options that would protect infants, however. In previous studies with HIV-positive women attending the same clinics, by comparison, greater knowledge about prevention of perinatal HIV transmission was reported, but women had fewer sexual relationships, fewer desired to have children, and they expected even more disapproval of having children from health professionals. We conclude that the rights of those with HIV to found a family depend as much on curing the ills of prejudice and discrimination, including among health professionals, as on medical interventions.     

A framework for developing reproductive health policies and programmes in Nepal

Based on experience in Nepal from 1996-2001, this paper presents a six-element framework to support governments in poor countries in developing and implementing reproductive health programmes. The six elements of the framework are: (i) collaborative planning and programming; (ii) strategic assessment; (iii) policy and strategy development; (iv) guideline and material development; (v) reproductive health programme management; and (vi) policy review. Its implementation calls for collaborative work between policymakers and programme managers at all levels of the health system, external donors and development agencies. Change in Nepal is constrained by poor human and financial resources, extremely difficult geography and strong cultural, religious and social traditions. An informal assessment at district level and below found that information tools, clinical protocols and operational guidelines were highly relevant, though problems with utilisation and motivation were noted. Utilisation of strategy and policy documents and tools was reported to be high at national level, but no causal link can be drawn between instruments in the framework and changes in reproductive health indicators. However, access to the tools described in this article can contribute to improvements in coverage and quality of reproductive health services in the hands of motivated people; improved indicators in family planning use, antenatal care and assisted delivery in Nepal in this period support this view.     

The need for priority reproductive health services for displaced Iraqi women and girls

Disregarding reproductive health in situations of conflict or natural disaster has serious consequences, particularly for women and girls affected by the emergency. In an effort to protect the health and save the lives of women and girls in crises, international standards for five priority reproductive health activities that must be implemented at the onset of an emergency have been established for humanitarian actors: humanitarian coordination, prevention of and response to sexual violence, minimisation of HIV transmission, reduction of maternal and neonatal death and disability, and planning for comprehensive reproductive health services. The extent of implementation of these essential activities is explored in this paper in the context of refugees in Jordan fleeing the war in Iraq. Significant gaps in each area exist, particularly coordination and prevention of sexual violence and care for survivors. Recommendations for those responding to this crisis include designating a focal point to coordinate implementation of priority reproductive health services, preventing sexual exploitation and providing clinical care for survivors of sexual violence, providing emergency obstetric care for all refugees, including a 24-hour referral system, ensuring adherence to standards to prevent HIV transmission, making condoms free and available, and planning for comprehensive reproductive health services.     

Expanding safer sex options: introducing the female condom into national programmes

Although the female condom has been introduced into over 90 countries since 1997, it has only been accepted in sexual and reproductive health programmes as a mainstream method in a few. This paper describes introductory strategies developed by Ministries of Health and non-governmental organisations in Brazil, Ghana, Zimbabwe and South Africa, supported by UNAIDS, and the manufacturers of the female condom, which have significantly expanded the number of female condoms being used. These projects have several key similarities: a focus on training for providers and peer educators, face-to-face communication with potential users to equip them with information and skills, an identified target audience, a consistent supply, a long assessment period to gauge actual use beyond the initial novelty phase, and a mix of public and private sector distribution. Female condom programmes require the sanction, leadership and funding of governments and donors. However, the non-governmental and private sectors have also played a major role in programme implementation. To ensure successful introduction of the female condom, it is crucial to involve a range of decision-makers, programme managers, service providers, community leaders and women's and youth groups. The rising cost of inaction and unprotected sex in the spread of HIV and AIDS force us to recognise the high cost of not providing female condoms alongside male condoms in family planning and AIDS prevention programmes.     

Health care students at an Argentinean school of medicine: are they well prepared to provide quality sexual and reproductive health services?

Objectives: The aim of our study was to assess what students of the University of Buenos Aires School of Medicine learn about sexual and reproductive health (SRH) and rights, focusing particularly on their knowledge of accessibility to contraception and abortion legislation.

Methods: In this cross-sectional study, self-administered, anonymous questionnaires were administered to 760 first year students and to 695 final year students from different fields of study (medicine, midwifery, nursing, radiology, nutrition, speech therapy and physiotherapy) between 2011 and 2013. Students’ knowledge of SRH was measured according to six variables: contraceptive methods, accessibility to contraception, emergency contraception, legislation on surgical contraception, legislation on voluntary interruption of pregnancy, and HIV transmission and prevention. Their level of knowledge was categorised as low, basic, medium or high, according to their responses.

Results: We observed higher levels of knowledge in final year students compared with first year students. Those with basic level knowledge or higher were doubled in most of the variables. However, when analysed in detail per field of study, the differences were not so marked. It is important that medical, midwifery and nursing students receive formal education in SRH topics.

Conclusions: Our investigation revealed important deficiencies in knowledge in core topics of SRH care among soon-to-be health care providers that could represent serious barriers to health and rights for the Argentinean population in the near future. Thus, there is an urgent need to improve the teaching of SRH care.     

Focus on women: linking HIV care and treatment with reproductive health services in the MTCT-Plus Initiative

Despite important advances in expanding access to antiretroviral therapy in the countries most heavily affected by HIV/AIDS, there has been little consideration of the connections between HIV prevention, care and treatment programmes and reproductive health services. In this paper, we explore the integration of reproductive health services into HIV care and treatment programmes. We review the design and progress of the MTCT-Plus Initiative, which provides HIV care and treatment services to HIV positive women as well as their HIV positive children and partners. By emphasising the long-term follow-up of families and the provision of comprehensive care across the spectrum of HIV disease, MTCT-Plus highlights the potential synergies in linking reproductive health services to HIV care and treatment programmes. While HIV care and treatment programmes in resource-limited settings may not be able to integrate all reproductive health services into a single service delivery model, there is a clear need to include basic reproductive health services, such as access to appropriate contraception and counselling and management of unplanned pregnancies. The integration of these services would be facilitated by greater insight into the reproductive choices of HIV positive women and men, and into how health care providers influence access to reproductive health services of people with HIV and AIDS.     

Making legal abortion available in Brazil: partnerships in practice.

This article describes the participation of feminist groups who work in the area of women's reproductive health and rights in campaigns for the provision of legal abortion in public hospitals in Brazil. Brazilian criminal law permits therapeutic abortion in cases where pregnancy is the result of rape or poses a serious risk to the life of the woman. Today, as a result of the combined efforts of feminists, health professionals and policymakers, more than 20 hospitals in Brazil are officially permitted to perform therapeutic abortions within the existing law. A model programme has also been developed to train service providers to do legal abortions, where the agreement of a hospital board can be obtained. This training has also improved care for illegally obtained, incomplete abortions in those hospitals but not in hospitals where doctors have not been trained. Problems with lack of access and concerns about the lack of public acceptance of abortion remain. Women not only need the right to abortion but also more services and health professionals who are trained to perform abortions across the whole country.     

Gender-related indicators for the evaluation of quality of care in reproductive health services

This paper is based on a decade of participative research with health institutions and women users of health services, and shared reflections with feminists working in women's health projects. It describes a study between 1993 and 1995 in rural and urban sectors of the Metropolitan Region of Chile, including the capital Santiago,¹ of the care women were receiving in public sector reproductive health services for contraception, childbirth and cervical cancer. The study aimed to produce a range of indicators for evaluating quality of care in those services from a gender perspective. The data generated four main variables in quality of care — the extent of improvement in a woman's health and well-being, the extent to which her expectations were met, the extent of respect shown to the woman as an individual and her rights, and the extent to which her autonomy was strengthened — as a result of the care provided. Indicators were developed arising from these variables and can be developed for all aspects of service delivery. They can be used by the women's health movement, users of services and health services themselves to train health professionals, and to recommend, lobby for and measure improvements in quality of care.     

HIV/AIDS in the shadows of reproductive health interventions

In December 1999, the Tanzanian president declared HIV/AIDS a national disaster. By the time the National Policy on HIV/AIDS was released in 2001, an estimated 750,000 women of reproductive age were infected. Yet in spite of the impact of HIV on reproductive health, AIDS and reproductive health programmes are still thought of and implemented through separate channels, to the detriment of both. However, although AIDS remains in the shadows of reproductive health interventions, the lack of AIDS talk does not lessen the impact of the disease on people's lives. During the course of my participant observations in maternal and child health/family planning (MCH/FP) clinics collected during 25 months of fieldwork in 10 clinics in Morogoro, Ruvuma and Kilimanjaro Regions, I rarely heard about AIDS. This article attempts to analyse why. Historically competing bureaucracies in MCH/FP and gender and development are not easily unified with a vertical HIV/AIDS control programme under the umbrella of "reproductive health". HIV/AIDS cannot merely be inserted into existing family planning programmes, re-named "reproductive health" programmes. As the AIDS epidemic is transformed through new technologies, reproductive health policy and priorities will be called into question and force us to look at the state of the African health care system, networks of care-giving, and how individuals and communities fail when there is no socio-economic safety net.