Expanding Reproductive Rights Knowledge among HIV-positive Women and Girls

In March 2009, ICW invited 15 to 20 HIV-positive women in each of the 3 participating communities to an introductory meeting which described the project and explained the topic of sexual and reproductive rights. From April to June 2009, meetings were held with the women where information was given and discussions were held about contraception, pregnancy, abortion, and sexual and reproductive rights.

Specifically, the project had 3 main objectives, divided into several activities:

1. Contribute to awareness-raising around, and de-stigmatisation of, the topics of unwanted pregnancy, HIV and reproductive rights, and unsafe abortion in the 3 selected communities. ICW members who had participated in previous workshops agreed to carry out community discussions - awareness-raising and educational in nature - with women living with HIV. The monthly sessions would be both informative and participatory, with a focus on unwanted pregnancy, unsafe abortion and safe abortion care. Ipas provided a curriculum of exercises and activities to structure the discussions in the months of March to July 2009. The topics covered were: making decisions about pregnancy, man-to-man letter (gender equity), problem tree about unwanted pregnancy, ideas and facts about contraception/emergency contraception, recognising early pregnancy, coping with teenage pregnancy, abortion-related exercises (what would you do?, should we let them die?), putting abortion in context (safe abortion: facts or fiction?, whom does my body belong to?), addressing stigma, the story of a T-shirt (wearing a shirt saying "I had an abortion" to evoke discussions), and closing discussion on unwanted pregnancy and abortion. Methods included role play, group discussions, question-and-answer segments, viewing of photos (e.g., of objects used in unsafe abortions) and demonstrations (e.g., of a manual vacuum aspiration (MVA) instrument).
2. Gather information regarding experiences of HIV-positive women with abortion that could be used in advocacy with civil society, legislators, and the media to promote the reproductive rights of women living with HIV/AIDS. During the discussion meetings, women were invited to relate stories about women (themselves, friends, or relatives) who had experience with an unwanted pregnancy and abortion. The facilitators explained that these stories were a way to give a "voice" to women who have terminated a pregnancy secretly because access to safe, legal abortion has not been available in Malawi. This activity was meant to show that these are common experiences, thereby contributing to de-stigmatisation among the participants, and to collect the testimonies for inclusion in a booklet that could be used as an advocacy tool with policymakers. In addition, women were invited to speak with ICW facilitators privately if they wished to share a story that could be included in the booklet.
3. Establish closer links with organisations and groups that are willing to advocate and support work on sexual and reproductive rights in Malawi. Ultimately, the booklet included 11 stories about abortion and 3 stories about women who had unintended pregnancies and carried them to term. The plan was that ICW would organise a meeting to "launch" the booklet of stories to which policymakers and civil society organisations would be invited; it was finally distributed at a meeting organised by others. ICW initiated more intensive contacts with colleague organisations by inviting guest speakers/facilitators to the April and June meetings. At the time of the project, Ipas was working with the World Health Organization and the Malawi Ministry of Health to carry out a strategic assessment of abortion and abortion-related services in the country. Part of this work involved holding capacity-building workshops with members of civil society organisations and the formation of a coalition to advocate for reproductive rights. ICW was invited to send participants to these workshops and meetings, thereby hopefully strengthening their visibility and recognition as a sexual and reproductive rights advocacy organisation. Other ICW members have since been invited to regional meetings on issues such as cervical cancer care, and the group has been invited to join other networks.

Women, Rights, Sexual and Reproductive Health, Maternal Health, HIV/AIDS.

According to organisers:

• In 2009, Malawi's adult national HIV prevalence (15-49 years) was 12.1% overall and 12.6% in pregnant women. A majority of transmissions were attributed to unprotected heterosexual intercourse. An estimated 930,000 people were living with HIV in Malawi, 60% of them women and girls (UNAIDS, 2008).
• Gender dynamics in Malawian society confer major decisionmaking powers on men. Overall, condom use is low, and some women's and girls' male partners prevent them from using contraceptives. These socio-demographic issues intersect with stigma and discrimination against those living with HIV/AIDS, especially for women and girls.
• Gender-based violence exacerbates women and girls' susceptibility to contracting HIV and sexually transmitted infections (STIs) and having unwanted pregnancies - "challenges that could be addressed through information, efforts to influence policymaking and capacity development of relevant grassroots structures."
• Modern contraceptive use rates in Malawi are 22.4% for all women and 17% for adolescents 15-19 years old, with 68% of girls having begun childbearing by the age of 19. "Girls and women in Malawi, including those living with HIV, have limited options for deciding how to deal with unintended and unwanted pregnancies. A lack of access to emergency contraception means that they either must carry the pregnancy to term, which may place them in very difficult and challenging life circumstances, try to obtain a safe abortion (which may involve great expense) or have an unsafe abortion.
• In Malawi, instances of child dumping (abandonment of newborns and infants) and unsafe abortion are increasing, according to the Family Planning Research Centre of Malawi (Gama, 2008). Their study, carried out in 4 districts, indicated that unsafe abortions are responsible for 16-40% of admissions to public hospital gynaecology wards for school-aged girls. In August 2010, Health Minister David Mphande confirmed this problem, stating: "It is obvious that we cannot achieve our MDG [Millennium Development Goal #5] target of 155 [maternal deaths] per 100,000 if abortion deaths alone are responsible for 200 deaths per 100,000 live births on our current maternal mortality rate of 807 per 100,000" (Ligomeka 2010).
• Malawi has ratified the Protocol on the Rights of Women for the African Charter on Human and People's Rights in 2005, which states that women should have access to safe legal abortion. However, current legislation only permits abortion in order to save a woman's life; other abortions are punishable by up to 14 years of imprisonment. The government has now worked with the World Health Organization (WHO) and Ipas to conduct a situation assessment of maternal morbidity and mortality related to unsafe abortion in the country (Reproductive Health Unit 2009). The preliminary report, issued in June 2009, stated that Malawi's maternal mortality ratio had scarcely declined since the early 1990s, with 807 women dying per 100,000 live births. As many as 24% of the deaths were due to unsafe abortions: an average of three to four deaths per day. The final report from the strategic assessment was disseminated in August 2010 to government and civil society representatives to discuss the implications for government policy.