- Email: [email protected]
Reproductive health without rights in Peru
REPRODUCTIVE HEALTH AND RIGHTS
are avoidable, it is easy to argue that maternal mortality is too high everywhere and that something must be done. We need reliable baselines from which to design intervention strategies and evaluate progress. In setting targets for 2015, the dilemma facing countries with hugely uncertain estimates (table) is not hard to imagine. Without adequate information, policy goals become alienated from action. The difficulty of relying on maternal mortality to monitor progress in the millennium development goal of improving maternal health has not been totally ignored. Indeed, a second target indicator has been advocated: the proportion of births attended by skilled health personnel—usually interpreted to mean doctors, midwives, and nurses. Argued to be a proxy or benchmark for maternal mortality, a global target has also been set for 2015 of 90%. Although the data requirements of this second indicator might seem less onerous, there are concerns about the relevance of measuring only the presence of a health professional rather than their skills or the delivery environment.3 Misrepresentation of skilled attendance has implications for meeting policy goals and for the quality of care achieved. The reliance on national estimates of the proportion of deliveries attended by health professionals has hidden the poor-rich gap in access to health care within countries, and its uncertain relation to maternal mortality. Without proof of a causal connection, increases in this proportion cannot be inferred as evidence of declining maternal mortality. The measurement of processes of care is not a substitute for the measurement of health effects in individuals and populations.
Bolivia Ghana Indonesia Nepal Yemen
Maternal deaths per 100 000 livebirths
Range of uncertainty
420 540 230 740 570
110–790 140–1000 58–440 440–1100 330–810
Estimated maternal mortality ratios for selected countries, 20002
In conclusion, we wish to draw attention to the perversity of promoting maternal mortality reduction as a goal for the 21st century without addressing the weaknesses of information systems to monitor progress. To deny women and their families the right for their health burden to be counted is to ignore the burden itself. This burden is not borne nor counted evenly within societies worldwide. It thus presents fundamental challenges to the poverty reduction strategies of developing countries and highlights inequities within many developed nations. References 1
2 3
Bouvier-Colle MH, Varnoux N, Costes P, Hatton F. Reasons for the underreporting of maternal mortality in France, as indicated by a survey of all deaths among women of childbearing age. Int J Epidemiol 1991; 20: 717–21. WHO, UNICEF, UNFPA. Maternal mortality in 2000: estimates developed by WHO, UNICEF and UNFPA. Geneva: 2003. SAFE International Research Partnership. SAFE strategy development tool: a guide for developing strategies to improve skilled attendance at delivery. Aberdeen: University of Aberdeen, 2003.
Reproductive health without rights in Peru J Jaime Miranda, Alicia Ely Yamin ne case of a surgical procedure that led to the death of a woman, where one of the charges was a failure to obtain fully informed consent, was debated at length by the UK General Medical Council last year.1 What about a quarter of a million cases? Between 1996 and 2000, more than 250 000 women, the overwhelming majority poor and from the remote, rural areas of the Andean sierra and Peruvian Amazon, underwent sterilisation, without a proper consent process, during the implementation of a family planning public-health policy in Peru.2,3 The Peruvian government was found responsible by the Inter-American Human Rights Commission in one emblematic case, in which Mamérita Mestanza Chávez had been forcibly sterilised and died as a result of the operation.4 Clearly the promotion of the right to health requires different approaches for different audiences and actors, but analysis of specific cases, such as that of reproductive health in Peru, can play a part in advancing this agenda.
O
Lancet 2004; 363: 68–69 International Health and Medical Education Centre, University College London, London, UK (J J Miranda MD); Department of Health Policy and Management, Harvard School of Public Health, Boston, MA, USA (A E Yamin JD); and EDHUCASalud, Lima, Peru (J J Miranda, A E Yamin) Correspondence to: Dr J J Miranda (e-mail: [email protected])
68
In Latin America, the world region with the greatest income disparities, Peru’s socioeconomic and health statistics are among the worst in terms of equity, with an especially stark contrast between urban and rural areas, which are heavily indigenous.5 25% of the population are women of reproductive age (15–49 years).6 The government programme sought to reduce the population growth rate to about 1·17%.7 The rate slowed from 2·8% in 1961–72, to 2·0% in 1981–93, reaching 1·7% in 1993–20026 during President Alberto Fujimori’s term. However, these averages mask disparities within the country. The national total fertility rate reached 2·2 in 2000, but in rural areas it remained at 4·3 and in many areas was much higher.5 Fujimori zealously pursued neoliberal economic development policies, which included population control as an integral part of limiting factors that could impede growth. In his second inaugural speech, in July, 1995, Fujimori announced that family planning would be priority for the government. Shortly after, Congress legalised sterilisation for family planning. In the context of a ministry of health that was marginal to the overall political agenda, Fujimori took a personal interest in the family planning programme, even monitoring its implementation directly.8 The Peruvian Human Rights Ombudsman’s Office, with human rights organisations and women’s groups, had an important role in documenting gross human rights violations during the implementation of the programme. The ombudsman, although a government institution, is
THE LANCET • Vol 363 • January 3, 2004 • www.thelancet.com
For personal use. Only reproduce with permission from The Lancet publishing Group.
REPRODUCTIVE HEALTH AND RIGHTS
THE LANCET • Vol 363 • January 3, 2004 • www.thelancet.com
Rights were not granted to include this image in electronic media. Please refer to the printed journal.
Panos Pictures
constitutionally autonomous, and has shown its independence in monitoring state compliance with constitutional rights. In 1998 and 2000, reports by the Ombudsman’s Office9,10 helped change government policy regarding surgical contraception. When the administration of President Alejandro Toledo assumed power in 2001, two investigations were launched into the reproductive health programme—both denounced the gross violations of women’s reproductive rights. Given this history, it is astonishing that in September, 2002, the Ombudsman’s Office issued another report,11 highlighting new problems in the health ministry generally and the family planning programme specifically that threaten women’s reproductive health and rights (http://www.ombudsman.gob.pe). The report documents restrictions on access to information about contraceptive methods, in particular surgical contraception. It notes how, despite the law and explicit policies of the family planning programme, charges are made for many reproductive services: fees for check-ups, new patients, medical record searches, issuing birth certificates for newborns; and fines for loss of identification documents, failures to attend follow-up appointments, and for women who deliver at home or do not receive antenatal care.11 Although some of these abuses existed under Fujimori, the new findings have a particular context. When Toledo assumed power, the ministry of health became dominated by conservative religious elements who have reframed reproductive health programmes within an ideological agenda,12 including restricting access to contraception and increasing already severe penalties for abortion. From a health policy perspective, the implementation of both programmes lacked quality control and used inappropriate incentives. For example, in the case of the sterilisations, local health-care providers were required to meet quotas, which created incentives for coercive, and at times negligent, behaviour. The same providers were later asked to generate and manage resources, even in tiny, remote health-care centres—leading to fees and fines. Similarly, policy directives from the ministry have had a chilling effect on front-line health-care workers offering information or certain contraceptive options to women. However, on another level, these cases illustrate the difference between a rights approach to reproductive health, which invests value in individuals’ capacities to take decisions that affect their lives and wellbeing, and a social engineering approach, whether based on the dogma of economic development or religious fundamentalism. Despite their different effects on contraceptive methods— one aimed at promoting surgical contraception and one aimed at curtailing it—these policies share at least three defects from a human rights perspective. First, they discriminate against women, whose reproductive capacities and health are at issue and whose autonomy and decisions are not respected. Second, they treat women—in particular poor, rural women—as objects of a policy rather than as people who have rights and are entitled to participate in decisions, programmes, and policies affecting their health at all levels. Both policies were imposed in a punitive and autocratic manner, leaving no room for the voice of individuals whose lives were (and are) affected. Third, there was not, and is not, a system of accountability through which individuals could obtain redress in the event of violation of their rights, which was noted when the Inter-American Commission admitted the case of Mamérita Mestanza Chávez. Furthermore, other lessons can be learned from this case. First, the government’s actions convert health-care providers into (often unwitting) participants in the systematic
Women in poor, rural areas were most affected by government policies
abuse of women’s rights, rather than enabling them to be agents in the promotion of human rights. Solutions to these problems must take into account the roles and rights of health professionals, as well as those of patients. Second, implementation of reproductive health policies for socially and economically marginalised populations, who often have little awareness of their rights, requires analysis of the complexity of these issues rather than reactive responses to specific problems. Neither programme had a health promotion approach, which includes legal and policy reform, sex education, and raising the awareness of rights for users and providers. Rather, in tackling the specific problems that each administration identified according to its political criteria, their policies coupled abuses in the public-health system with limitations on the reproductive health of impoverished women. In July, 2003, Toledo appointed a new minister of health who has promised encouraging reforms within the ministry with respect to reproductive health policies. It remains to be seen whether lessons are learned from past mistakes. References 1
Dyer C. Gynaecologists cleared of wrongdoing after death of patient. BMJ 2002; 325: 674. 2 Bosch X. Former Peruvian government censured over sterilisations. BMJ 2002; 325: 236. 3 Mass sterilisation scandal shocks Peru. BBC News, July 24, 2000. 4 Case 12.191. Report No 66/00 María Mamérita Mestanza Chávez. Washington: Inter-American Commission on Human Rights, 2000. 5 Instituto Nacional de Estadística e Informática. Encuesta nacional demográfica y de salud 2000. Lima: INEI, 2000. 6 Instituto Nacional de Estadística e Informática. Perú en cifras. http://www.inei.gob.pe (accessed May 12, 2003). 7 Population: brickbats and bouquets for Peruvian policies. Inter Press Service, Nov 14, 1997. 8 Gobierno ordenaba a médicos cumplir cuotas de mujeres esterilizadas. La República, Sept 23, 2001. 9 Defensoría del Pueblo. Informe Defensorial No 7. Lima: Defensoría del Pueblo, October, 2002. 10 Defensoría del Pueblo. Informe Defensorial No 27. Lima: Defensoría del Pueblo, January, 2000. 11 Defensoría del Pueblo. Informe Defensorial No 69. Lima: Defensoría del Pueblo, November, 2002. 12 Coe AB, Jacobson J. Government extremists in Peru further undermine reproductive rights. Takoma Park: CHANGE, 2002.
69
For personal use. Only reproduce with permission from The Lancet publishing Group.
are avoidable, it is easy to argue that maternal mortality is too high everywhere and that something must be done. We need reliable baselines from which to design intervention strategies and evaluate progress. In setting targets for 2015, the dilemma facing countries with hugely uncertain estimates (table) is not hard to imagine. Without adequate information, policy goals become alienated from action. The difficulty of relying on maternal mortality to monitor progress in the millennium development goal of improving maternal health has not been totally ignored. Indeed, a second target indicator has been advocated: the proportion of births attended by skilled health personnel—usually interpreted to mean doctors, midwives, and nurses. Argued to be a proxy or benchmark for maternal mortality, a global target has also been set for 2015 of 90%. Although the data requirements of this second indicator might seem less onerous, there are concerns about the relevance of measuring only the presence of a health professional rather than their skills or the delivery environment.3 Misrepresentation of skilled attendance has implications for meeting policy goals and for the quality of care achieved. The reliance on national estimates of the proportion of deliveries attended by health professionals has hidden the poor-rich gap in access to health care within countries, and its uncertain relation to maternal mortality. Without proof of a causal connection, increases in this proportion cannot be inferred as evidence of declining maternal mortality. The measurement of processes of care is not a substitute for the measurement of health effects in individuals and populations.
Bolivia Ghana Indonesia Nepal Yemen
Maternal deaths per 100 000 livebirths
Range of uncertainty
420 540 230 740 570
110–790 140–1000 58–440 440–1100 330–810
Estimated maternal mortality ratios for selected countries, 20002
In conclusion, we wish to draw attention to the perversity of promoting maternal mortality reduction as a goal for the 21st century without addressing the weaknesses of information systems to monitor progress. To deny women and their families the right for their health burden to be counted is to ignore the burden itself. This burden is not borne nor counted evenly within societies worldwide. It thus presents fundamental challenges to the poverty reduction strategies of developing countries and highlights inequities within many developed nations. References 1
2 3
Bouvier-Colle MH, Varnoux N, Costes P, Hatton F. Reasons for the underreporting of maternal mortality in France, as indicated by a survey of all deaths among women of childbearing age. Int J Epidemiol 1991; 20: 717–21. WHO, UNICEF, UNFPA. Maternal mortality in 2000: estimates developed by WHO, UNICEF and UNFPA. Geneva: 2003. SAFE International Research Partnership. SAFE strategy development tool: a guide for developing strategies to improve skilled attendance at delivery. Aberdeen: University of Aberdeen, 2003.
Reproductive health without rights in Peru J Jaime Miranda, Alicia Ely Yamin ne case of a surgical procedure that led to the death of a woman, where one of the charges was a failure to obtain fully informed consent, was debated at length by the UK General Medical Council last year.1 What about a quarter of a million cases? Between 1996 and 2000, more than 250 000 women, the overwhelming majority poor and from the remote, rural areas of the Andean sierra and Peruvian Amazon, underwent sterilisation, without a proper consent process, during the implementation of a family planning public-health policy in Peru.2,3 The Peruvian government was found responsible by the Inter-American Human Rights Commission in one emblematic case, in which Mamérita Mestanza Chávez had been forcibly sterilised and died as a result of the operation.4 Clearly the promotion of the right to health requires different approaches for different audiences and actors, but analysis of specific cases, such as that of reproductive health in Peru, can play a part in advancing this agenda.
O
Lancet 2004; 363: 68–69 International Health and Medical Education Centre, University College London, London, UK (J J Miranda MD); Department of Health Policy and Management, Harvard School of Public Health, Boston, MA, USA (A E Yamin JD); and EDHUCASalud, Lima, Peru (J J Miranda, A E Yamin) Correspondence to: Dr J J Miranda (e-mail: [email protected])
68
In Latin America, the world region with the greatest income disparities, Peru’s socioeconomic and health statistics are among the worst in terms of equity, with an especially stark contrast between urban and rural areas, which are heavily indigenous.5 25% of the population are women of reproductive age (15–49 years).6 The government programme sought to reduce the population growth rate to about 1·17%.7 The rate slowed from 2·8% in 1961–72, to 2·0% in 1981–93, reaching 1·7% in 1993–20026 during President Alberto Fujimori’s term. However, these averages mask disparities within the country. The national total fertility rate reached 2·2 in 2000, but in rural areas it remained at 4·3 and in many areas was much higher.5 Fujimori zealously pursued neoliberal economic development policies, which included population control as an integral part of limiting factors that could impede growth. In his second inaugural speech, in July, 1995, Fujimori announced that family planning would be priority for the government. Shortly after, Congress legalised sterilisation for family planning. In the context of a ministry of health that was marginal to the overall political agenda, Fujimori took a personal interest in the family planning programme, even monitoring its implementation directly.8 The Peruvian Human Rights Ombudsman’s Office, with human rights organisations and women’s groups, had an important role in documenting gross human rights violations during the implementation of the programme. The ombudsman, although a government institution, is
THE LANCET • Vol 363 • January 3, 2004 • www.thelancet.com
For personal use. Only reproduce with permission from The Lancet publishing Group.
REPRODUCTIVE HEALTH AND RIGHTS
THE LANCET • Vol 363 • January 3, 2004 • www.thelancet.com
Rights were not granted to include this image in electronic media. Please refer to the printed journal.
Panos Pictures
constitutionally autonomous, and has shown its independence in monitoring state compliance with constitutional rights. In 1998 and 2000, reports by the Ombudsman’s Office9,10 helped change government policy regarding surgical contraception. When the administration of President Alejandro Toledo assumed power in 2001, two investigations were launched into the reproductive health programme—both denounced the gross violations of women’s reproductive rights. Given this history, it is astonishing that in September, 2002, the Ombudsman’s Office issued another report,11 highlighting new problems in the health ministry generally and the family planning programme specifically that threaten women’s reproductive health and rights (http://www.ombudsman.gob.pe). The report documents restrictions on access to information about contraceptive methods, in particular surgical contraception. It notes how, despite the law and explicit policies of the family planning programme, charges are made for many reproductive services: fees for check-ups, new patients, medical record searches, issuing birth certificates for newborns; and fines for loss of identification documents, failures to attend follow-up appointments, and for women who deliver at home or do not receive antenatal care.11 Although some of these abuses existed under Fujimori, the new findings have a particular context. When Toledo assumed power, the ministry of health became dominated by conservative religious elements who have reframed reproductive health programmes within an ideological agenda,12 including restricting access to contraception and increasing already severe penalties for abortion. From a health policy perspective, the implementation of both programmes lacked quality control and used inappropriate incentives. For example, in the case of the sterilisations, local health-care providers were required to meet quotas, which created incentives for coercive, and at times negligent, behaviour. The same providers were later asked to generate and manage resources, even in tiny, remote health-care centres—leading to fees and fines. Similarly, policy directives from the ministry have had a chilling effect on front-line health-care workers offering information or certain contraceptive options to women. However, on another level, these cases illustrate the difference between a rights approach to reproductive health, which invests value in individuals’ capacities to take decisions that affect their lives and wellbeing, and a social engineering approach, whether based on the dogma of economic development or religious fundamentalism. Despite their different effects on contraceptive methods— one aimed at promoting surgical contraception and one aimed at curtailing it—these policies share at least three defects from a human rights perspective. First, they discriminate against women, whose reproductive capacities and health are at issue and whose autonomy and decisions are not respected. Second, they treat women—in particular poor, rural women—as objects of a policy rather than as people who have rights and are entitled to participate in decisions, programmes, and policies affecting their health at all levels. Both policies were imposed in a punitive and autocratic manner, leaving no room for the voice of individuals whose lives were (and are) affected. Third, there was not, and is not, a system of accountability through which individuals could obtain redress in the event of violation of their rights, which was noted when the Inter-American Commission admitted the case of Mamérita Mestanza Chávez. Furthermore, other lessons can be learned from this case. First, the government’s actions convert health-care providers into (often unwitting) participants in the systematic
Women in poor, rural areas were most affected by government policies
abuse of women’s rights, rather than enabling them to be agents in the promotion of human rights. Solutions to these problems must take into account the roles and rights of health professionals, as well as those of patients. Second, implementation of reproductive health policies for socially and economically marginalised populations, who often have little awareness of their rights, requires analysis of the complexity of these issues rather than reactive responses to specific problems. Neither programme had a health promotion approach, which includes legal and policy reform, sex education, and raising the awareness of rights for users and providers. Rather, in tackling the specific problems that each administration identified according to its political criteria, their policies coupled abuses in the public-health system with limitations on the reproductive health of impoverished women. In July, 2003, Toledo appointed a new minister of health who has promised encouraging reforms within the ministry with respect to reproductive health policies. It remains to be seen whether lessons are learned from past mistakes. References 1
Dyer C. Gynaecologists cleared of wrongdoing after death of patient. BMJ 2002; 325: 674. 2 Bosch X. Former Peruvian government censured over sterilisations. BMJ 2002; 325: 236. 3 Mass sterilisation scandal shocks Peru. BBC News, July 24, 2000. 4 Case 12.191. Report No 66/00 María Mamérita Mestanza Chávez. Washington: Inter-American Commission on Human Rights, 2000. 5 Instituto Nacional de Estadística e Informática. Encuesta nacional demográfica y de salud 2000. Lima: INEI, 2000. 6 Instituto Nacional de Estadística e Informática. Perú en cifras. http://www.inei.gob.pe (accessed May 12, 2003). 7 Population: brickbats and bouquets for Peruvian policies. Inter Press Service, Nov 14, 1997. 8 Gobierno ordenaba a médicos cumplir cuotas de mujeres esterilizadas. La República, Sept 23, 2001. 9 Defensoría del Pueblo. Informe Defensorial No 7. Lima: Defensoría del Pueblo, October, 2002. 10 Defensoría del Pueblo. Informe Defensorial No 27. Lima: Defensoría del Pueblo, January, 2000. 11 Defensoría del Pueblo. Informe Defensorial No 69. Lima: Defensoría del Pueblo, November, 2002. 12 Coe AB, Jacobson J. Government extremists in Peru further undermine reproductive rights. Takoma Park: CHANGE, 2002.
69
For personal use. Only reproduce with permission from The Lancet publishing Group.