How to improve access to sexual, reproductive health services

•Concept promotes social inclusiveness, reduces maternal mortality, unplanned pregnancies, and unsafe abortion among adolescent girls, women

Sexual and reproductive health is a state of complete physical, mental, and social well-being in all matters relating to the reproductive system. This implies that people can have a satisfying and safe sex life, the capability to reproduce and the freedom to decide if, when, and how often to do so.

The Federal Government of Nigeria in collaboration with several partners over the past years has made significant efforts to ensure that access to sexual and reproductive health services and rights is made available at all levels of health care to support vulnerable populations.

Several studies have shown that vulnerable populations have the same sexual and reproductive health needs, as others not deemed vulnerable.

Director, Family Health Department, Federal Ministry of Health, Dr. Salma Ibrahim Anas, in an opening address at the Knowledge Café/Webinar Series on ‘Expanding Access to Sexual and Reproductive Health Services and Rights to Vulnerable Populations’ held at Utako, Abuja and virtually on November 24, 2022, said the vulnerable populations need the same minimum package of reproductive health services available to everyone else; however, their special circumstances often create barriers to access.

Such barriers, according to Anas, include, but are not limited to: communication of information, ignorance of service providers, societal attitude, and inadequate capacity of service providers to manage clients with disabilities. These, she said, can combine to deny persons with disabilities basic reproductive health services.

Salma said the current humanitarian situation in Nigeria has aggravated the reproductive health risk, that persons with disabilities suffer. She said attention to this cluster of people is usually inadequate and is not planned for, hence difficult to harvest concrete results.

Salma said the Basic Health Care Provision Fund is the strategy of the government to ensure the inclusivity of all persons including vulnerable groups in the spirit of leaving no one behind the Universal Health Coverage (UHC).

She said other efforts of the government include the provision of family planning services, which has been expanded through the introduction of new approaches and an array of method mixes. The director said the renewed commitment to family planning among government and all levels as well as donor partners has stimulated wider coverage of services accompanied by greater emphasis on quality and human rights.

Salma said the renewed focus on adolescent and young persons’ sexual and reproductive health has spurred interest in better ways to reach adolescents with effective messages and services. She said articulation of policies to protect everyone include the of ‘Prohibition of Violence Again Persons’, which does not discriminate against anyone.

She said partnering with and inclusion of traditional and religious leaders in sexual and reproductive health to address socio-cultural norms like stigmatisation has been made a priority for government at all levels.

Salma commended all stakeholders who have been resolute in ensuring that all Nigerians of reproductive age have access to quality sexual and reproductive health services and to Marie Stopes International Organisation Nigeria (MSION) particularly for organising the webinar to further draw attention to this very important topic.

The theme of the webinar was, ‘Expanding access to sexual and reproductive health services and rights to vulnerable populations.’

Some of the topics discussed include: What innovations and strategies have proven to be effective in driving Sexual and Reproductive Health (SRH) programmes for adolescents? What intergenerational norms impede Sexual and Reproductive Health Rights (SRHR) and how can we ensure a positive shift that includes adolescents?

Norm change interventions strategies and innovations targeting adolescents: Experiences and lessons from MSION. What are the innovations and strategies that have proven to be effective in driving SRH programmes for People with Disabilities (PWD)? Norm change interventions, strategies and innovations targeting PWDs: Experiences and lessons from MSION.

The webinar was divided into two breakaway sessions- adolescents and people with disabilities- for better participation.

Director of Programmes at MSION, Ogechi Onuoha, who spoke on ‘Challenging Social Norms to Reach Persons with Disabilities with Sexual and Reproductive Health Services– MSION’s Experience/Lessons learnt’, said: “Everyone deserves the right to make their own choices about their bodies and futures. Yet, many people with disabilities are denied that choice.
 
In Nigeria, the 2018 National Demographic Health Survey (NDHS) revealed that seven per cent of household members aged five and above have a disability in at least one functional domain — seeing, hearing, communication, cognition, walking, or self-care.

“Since 2018, MSION through the Women Integrated Sexual Health (WISH) project a United Kingdom (UK) The Foreign, Commonwealth & Development Office (FCDO’s) flagship sexual and reproductive healthcare programme with the key aim to ensure we leave no one behind, is delivering access for communities often marginalised from healthcare, such as adolescents and people with disabilities.”

She said social norms MSION is addressing include: people with disability are not sexually active and people with disability do not need contraception/other SRH services.

She said they are removing barriers with government and community partnership – effective community entry. “We initiate and nurture influential relationships with the government and community to secure and sustain interest and support for PWD. This support cascades down to community members, paving the way for greater acceptance; for example, communities supporting service uptake for PWD. Engagement of PWD organisations and individuals as change agents and satisfied clients to create/reinforce positive social norms by modelling desired behaviour,” Onuoha said.

She said social norms impact adolescent access at multiple levels, and MSION intervenes at these levels: “MSION’s Community health workers and social behaviour change agents engage PWD and the community to show how SRH enables better health and life outcomes for the client. Value Clarification and Attitude Training (VCAT) for providers ensured the provision of unbiased and friendly SRH services. Toll-Free Contact centre ensures a continuum of care in SRHR services to women and girls across Nigeria regardless of disability status. Intervene at community, facility, and through the referral, the pathway to connect clients to services and ensure client satisfaction,” Onuoha said.

On lessons learnt, she said: “Empowering PWD with SRHR information will enable them to make an informed decision about their lives and future.

“Increase awareness of the range of sexual and reproductive healthcare services available to people with disabilities, and the right to empowering care, for all.

“Disability Abortion values clarification and attitude transformation (VCAT) for providers and team members to ensure the provision of unbiased PWD-friendly SRH services.

“Partnering with Organisations of Persons with Disabilities to design inclusive services is key.”

MSION work collaboratively with the government at national, state, and Local Government Area (LGA) levels to support and strengthen government healthcare delivery including the private health sector in 36 states plus the Federal Capital Territory (FCT).

The organisation offers comprehensive SRH services that enable women all over Nigeria to choose their reproductive health future through various service delivery channels. Their services include contraception, Comprehensive Post-Abortion Care (CPAC), Sexually Transmitted Infection (STI) testing and treatment, maternal and child health care, and health systems strengthening.

“We tailor services and approaches to addressing the unique challenges of the client by employing several channels of service delivery to ensure no one is left behind,” she said.

Representative of the Society for Family Health (SFH), Dr. Jennifer Anyanti, in her presentation on ‘Approaches to Scaling up ASRH in Nigeria’, said Nigeria has made very slow progress on contraceptive prevalence rate (CPR). Anyanti said unmet need remains stubbornly high; room for CPR growth exists, even if demand does not change.

Several analyses have examined the relationship between modern contraceptive prevalence rates (mCPR) and the number of modern methods used by women of reproductive age.

The availability of a variety of contraceptive methods helps in meeting the individual needs of women and couples. A recent article by Ross and Stover demonstrates that contraceptive use is greater when more methods are available to a large proportion of the population.

The authors describe a positive association between modern contraceptive prevalence rates (mCPR; from representative national surveys) and the number of modern methods available (based on scores from the Family Planning Effort Index). Here, we examine the relationship between mCPR and the number of modern methods actually being used, based on method prevalence rates from nationally representative surveys.

Anyanti said studies have demonstrated a positive correlation between mCPR and the number of methods used by women and couples. She said women and couples are more likely to use modern contraception to prevent pregnancy if they have access to more types of modern methods.

She urged the Federal Government to prioritise adolescent girls’ access to sexual reproductive health services to reduce morbidity and maternal mortality.

Anyanti said access to reproductive health services would promote social inclusiveness and help reduce maternal mortality such as unplanned pregnancies and unsafe abortion among adolescent girls and women.

She highlighted the achievements of the 360/Levonorgestrel Intrauterine System (LNG IUS) project to include adolescents and their parents’ engagement in the use of modern contraceptives in the prevention of unwanted pregnancies and birth control. LNG IUS is one of the most effective forms of reversible contraception. Others include the empowerment of adolescent girls, the creation of adolescent-friendly sexual reproductive health facilities, and easy accessibility.

On the intergenerational norms impeding SRHR for persons with disabilities and how they can ensure a positive shift that includes persons with disabilities, Executive Director, Deaf Women Aloud Initiative (DWAI), National President, Deaf Women Association of Nigeria and 2021 Mandela Washington Fellow (MWF), Hellen Anurika Beyioku-Alase, said: “According to the World Health Organisation (WHO) 2011 Report on World Population, it is estimated that 15 per cent of every country’s population is persons with disabilities. In Nigeria, with a population of over 200 million, there are over 35 million persons with disabilities including women and children.

“Universal Health states that all people have right to access health services they need, when and where they need them, without financial hardship. It includes the full range of essential health services, from health promotion to prevention, treatment, rehabilitation, and much more.”

On intergenerational norms impeding SRHR, Beyioku-Alase identified tradition, religion, patriarchy, negative perception, myths and misconceptions. She said traditional people see People With Disabilities (PWDs) as abnormal, that they are taboo or an abomination they believe that they are outcasts and have evil spirit. “To them, their disabilities are as a result of a generational curse,” Beyioku-Alase.

She said religion sees Women With Disabilities (WWDs) as sinful and sick that they need healing from their diseases. “They also wonder how can a sick person mingle get married or have a sexual life, access to family planning and take contraceptives,” Beyioku-Alase said.

On patriarchy, she said due to gender inequality WWDs are marginalised. “It is triple the effects, because of their gender, disability, and because they are often the poorest of the poor compared to men with disabilities WWDs still face barriers to SRHR because of cultural belief,” she said.

Beyioku-Alase said because of ignorance, family and society have formed negative perceptions about WWDs, they believe they cannot have children, get married or make choices about who their life partner should be and that they cannot raise children. “For example when WWD is pregnant and tries to access ante-natal care we often hear words like “madam you no pity yourself” from health providers,” she said.

She said myths and misconceptions from a lot of stories about WWDs affect their SRHR. “For example women with disabilities are not sexually active, WWDs are completely dependent on their families in all areas including their sexuality, raping women with Albinism brings good luck, deaf people are ‘dumb’. Misconceptions about disabilities often lead to name-calling, which further affects their SRH needs. Names like a cripple, imbecile, deaf and dumb, mum (stupid). Just imagine women who are called such names coming to the facility to access care,” she said.

On how norms affect WWDs SRH, Beyioku-Alase said intergenerational norms leads to barriers for women with disabilities in accessing sexual and reproductive health services, it includes the following: negative attitudes of service providers towards WWDs; poor government funding for SRH of WWDs; lack of inclusive service for WWDs in health facilities, for example, no sign language interpreters, Braille materials and Ramps; lack knowledge/awareness of service providers on disability inclusion; WWDs are not given the opportunity to make the decision for themselves when it comes to their SRH need; and lack of awareness and information on family planning, contraceptives and abortion to women with disabilities.

On how Nigeria can ensure a positive shift that includes person with disabilities, Beyioku-Alase recommended: public awareness on the health rights of women with disabilities; government should have accessible budgetary line for WWDs SRH needs; stakeholders in the health sector should work together to put mechanisms in place that protect the SRHR of young women with disabilities; exiting health policies should be implemented for easy SRH access for women with disabilities; make healthcare facilities accessible by providing sign language interpreters, health information on Braille and Ramps; raise more awareness through evidence-based research findings; persons with disabilities are experts in their own rights, they can comprehend and make decisions like every other person, do not speak for them; demystify misconceptions and myths in reproductive health for women with disabilities by training health providers on disability inclusion; and conduct needs assessment in health facilities so as to make it accessible for women with disabilities.

She concluded: “As women with disabilities our impairments is not a barrier to access but the society, therefore, It is important to remove the prejudice and misinformation about the sexual and reproductive health rights of persons with disabilities and allow us have access to our health rights just like every other person.”

Head, Women and Gender, National Commission for Persons With Disabilities, Patience Ogolo-Dickson, in her presentation titled ‘Innovations and Strategies for effective SRH Programmes for PWDs/ Women and Girls with Disabilities (WGWD)’, said PWDs have the same SRH needs as persons without disabilities and WWDs face unique barriers to the full realisation of their sexual and reproductive health.

Ogolo-Dickson said forms and manifestations of barriers include: access to physical health facilities; access to SRH information; discriminatory SRH care; lack of decision-making and personal autonomy; and discrimination and stigma.

She said the government have obligation to respect, protect and fulfil SRH for all WWE. She said the government has the obligation to ensure SRH services are: available, accessible, acceptable and quality.

On effective strategies for SRH programmes in PWDs/WGWD, Ogolo-Dickson recommended: technology-driven SRH programmes for PWDs; boosting data collection by developing an app that records disability and SRH considering disability type and needs; provision of quality services, aftercare and confidentiality; training of health workers; promotion of positive outcomes for WGWDs regarding pregnancy, birth, maternal health etc., and education of WWDs on family planning and safe abortion; empowerment of PWDs, including in SRH and right to their bodies; improve and easy access to health facilities, access to SRH Information, provision of SLI; and increased awareness and sensitisation of the community.

Meanwhile, there exist prospects and opportunities for the protection of SRHRs in the Nigerian legal system. Nigeria has ratified several international/regional human rights instruments, which seek to protect sexual and reproductive rights. There are also some human rights provisions contained in the constitution and some other provisions on Federal and State legislation that are gender-based.

There are also reports on Millennium Development Goals and National Reproductive Health Policies, which show that there are prospects and opportunities that the government can protect women’s reproductive health and rights in Nigeria. Nonetheless, there is undoubtedly room for improvement in the protection of this particular genre of rights of women in Nigeria and studies have proffered country-centric recommendations, which cut across options of amending relevant Constitutional and Federal/State legislations on SRHRs.

It is believed that Nigeria will certainly benefit from an implementation of the National Reproductive Health policies that have evolved over time and domesticating some of the international and regional instruments that have been ratified like the Convention on the Elimination of All Forms of Discrimination against Women (CEDAW) whilst enacting a National Reproductive Health Law by National Assembly, which will be uniformly adopted and implemented throughout the country.

CEDAW, adopted in 1979 by the United Nations (UN) General Assembly, is often described as an international bill of rights for women. Consisting of a preamble and 30 articles, it defines what constitutes discrimination against women and sets up an agenda for national action to end such discrimination.