The Social Architects
This report, TSA’s fourth, outlines the findings of the organization’s September 2013 field mission on coercive contraception clinics in Kilinochchi District. In early September of this year, activists in Kilinochchi discovered that public health workers had administered the sub-dermal contraceptive implant, Jadelle, to women from Veravil, Keranchi, and Valaipaddu during a nutrition clinic. After publishing accounts from these women, TSA traveled to Kilinochchi for an in-depth follow up investigation.

This report confirms that public health workers used coercive tactics to convince women to accept Jadelle. This egregious disregard for medical ethics and protocol constitutes serious violations of a woman’s rights to informed consent, reproductive autonomy, and health.

TSA visited the Veravil, Keranchi, Valaipaddu, Umaiyalpuram, and Malaiyalapuram villages, where Internally Displaced Persons (IDPs) have begun to rebuild their post-war lives. TSA interviewed twenty-three women ranging in age from fifteen to forty-three, members of the Ministry of Health (MoH), Kilinochchi, field level health workers, and community leaders. TSA worked on a very tight deadline and was under constant military surveillance throughout the course of this research.
The report includes eight conclusions:

1. Women in these villages lack adequate access to primary care.
2. Women lack adequate access to quality contraceptive services.
3. Public health workers asked women to come to a government sponsored nutrition clinic under false pretenses.
4. Government health workers coerced women into taking the implant.
5. Government health workers did not provide adequate counseling and women did not give full and informed consent.
6. Government health workers failed to conduct adequate medical pre-screening and to provide post-implant care instructions.
7. Public health employees failed to provide information to women who accepted the implant.
8. Women feel unsafe asking doctors questions. Government employees have told their subordinates to remain silent on this issue –perpetuating a culture of impunity.

Finally, this report urges the Government and civil society organizations to conduct a comprehensive investigation, to hold reproductive health and rights trainings for women and public health employees, to provide information on the implant in Tamil, to ensure adequate staffing at the field level, to develop a complaint mechanism for the public health system, to create a checklist for implant insertion, and to meet with women in these villages to explain removal, steps taken for accountability, and alternate forms of contraception.

The World Health Organization (WHO) and International Conference on Population and Development (ICPD) define reproductive rights as: “the recognition of the basic right of all couples and individuals to decide freely and responsibly the number, spacing and timing of their children and to have the information and means to do so, and the right to attain the highest standard of sexual and reproductive health. They also include the right of all to make decisions concerning reproduction free of discrimination, coercion and violence.”

In light of these fundamental rights TSA reiterates: Women have a right to understand the benefits and potential side effects of all available contraceptive options that they may require at different stages of their lives. They have the right to accept or deny any form of contraception at any time. Removing the implant requires a medical intervention (unlike pills), therefore reducing a woman’s control over her reproductive self-determination. Contraceptive counseling with an emphasis on free choice is especially important in conflict zones where women already have fewer options, inadequate information, and limited access to primary health services including contraception. Misleading women into hospital visits, presenting false medical information, and the failure to ensure a woman’s right to make an informed, meaningful choice amounts to coercion and force – clear violations of women’s autonomy, well-being, dignity and bodily integrity.

Coerced medical procedures constitute cruel, inhuman, and degrading treatment under international law.

Recommendations
To ensure accountability, basic health facilities, and the reproductive rights of women in Umaiyalpuram, Malaiyalapuram, Keranchi, Veravil, and Valaipaddu, TSA recommends:

To the Government of Sri Lanka

• Conduct an in depth MOH and civil society investigation on Jadelle implant insertions in the North.
• Conduct a comprehensive health and reproductive health survey for Kilinochchi District with results made public.
• Provide information on the implant in Tamil and English. Information should also be available for women who cannot read. Adequate information should be provided at all health centers. Women should be able to take the information home.
• Appoint adequate midwives, nurses, and doctors in Kilinochchi immediately, as per government schemes and policies
• For the MOH to develop an easily accessible complaint mechanism for women with questions, comments or concerns regarding their experiences with the public health system.
• For the MOH to create a mandatory check-list for counseling, pre-insertion counseling, and post-care instructions for each implant insertion.
• For the MOH to conduct a reproductive rights training for doctors, nurses, and midwives.
• For the MOH to conduct a reproductive rights training for doctors, nurses, and midwives.
• Reduce the presence of military personnel in the Northern Province.
• Provide accurate statistics about militarization to the public.

To Civil Society

• Conduct trainings on reproductive health in villages in Kilinochchi District.
• Conduct a reproductive rights training for doctors, nurses, and midwives.
• Provide these women with information on removal in a language they understand and hold several village-wide meetings to explain the implant, steps for accountability, the clinic, and alternate forms of contraception.

To Bayer, the manufacturer

• Ensure that all doctors and nurses are familiar with the training manual for family planning for counseling, screening, insertion, and post-insertion care.
• Conduct trainings for doctors and nurses per the Jadelle training manual for family planning.

To the International Community

• Conduct a rights-based review of family planning, contraceptive services, and reproductive health projects in Sri Lanka.
• To review whether funding for Jadelle, an expensive contraceptive represents a rational public health expenditure.
• To consult with local community groups and CSOs to ensure that projects and programs are tailored to individual community needs.
• To urge the GoSL to publicize health indicators from the North and East.
• To pressure the GoSL to fulfill its international obligations under CEDAW, CRC, and ICESCR.
• For UNFPA, as funder for this project, to undertake a thorough study on what went wrong in these Kilinochchi villages.

The contents of the full report can be downloaded below:

• Above the Law: Violations of Women’s Reproductive Rights in Northern Sri Lanka (full report as Word or PDF)
• Annex 1: The Basic information of the villages of Kilinochchi District (as Word or PDF)
• Annex 2: Jadelle Patient Leaflet (PDF)
• Annex 3: Interviews with women and local and district health experts and service providers (as Word or PDF)
• Annex 4: Jaddelle Proof Of Implant (PDF)
• Annex 5: Post Insertion Health Record (PDF)
• Annex 6: Photos (PDF)

Or download all the documents as a ZIP file here (6Mb).

– Courtesy – Groundviews