UPR Submission for Sierra Leone

38th UPR Session May 2021

Organisations submitting the report

This is a joint submission for the UPR from Edmund Rice International (ERI) and the Congregation of the Good Shepherd (both ECOSOC Accredited).

EDMUND RICE INTERNATIONAL is an international non-governmental organization, founded in 2005 and with Special Consultative Status with ECOSOC since 2012. ERI is supported by two Catholic Religious Congregations, the Christian Brothers and the Presentation Brothers. It works with networks of like-minded organisations and in the countries where the two Congregations are present. ERI has a special interest in the rights of the child, the right to education and in eco-justice.

THE CONGREGATION OF OUR LADY OF CHARITY OF THE GOOD SHEPHERD is a Catholic religious order that was founded in 1835 by Saint Mary Euphrasia Pelletier in Angers, France. The sisters belong to a Catholic international congregation of religious women dedicated to promoting the welfare of women and girls

Preamble

1. Of all the recommendations of the 2nd Cycle of the UPR that were made to the government of Sierra Leone 78 were related specifically to the rights of women and girls. Of the recommendations supported by the government 53 were concerned with women and girls.[1] In 2016 at the Review mechanism of the human rights council Sierra Leone agreed to take 49 different actions to support the rights of women and girls.

2. In the report of Sierra Leone there is no mention of Obstetric Fistula. This is a lack. Pointing to the weak regard for the rights of women in a country known for its strong patriarchal stereotypes. [2]The absence of reference to this issue in the UPR reports (to date) of Sierra Leone is a gross neglect on the part of all the government departments of Sierra Leone. It is a further instance of the exclusion of women and their contribution to the life of the country. There is a general silence about this topic in the media and in public discourse in Sierra Leone. It is time to bring this issue out of the shadows.

3. The focus of this submission is on obstetric fistula in the context of a range of human rights, including poverty, health, education and disability. Issues of prison conditions and corruption are also the subject of recommendations.

Background

4. An estimated 2 million women[3] and girls in Africa are suffering from obstetric fistula caused by prolonged, obstructed childbirth and lack of access to maternity care. Left incontinent, they are often condemned to a life of solitude and despair.

5. Obstetric fistula, is a preventable and treatable condition that becomes a tragedy for many women coming from poor rural areas in sub-Saharan Africa.[4]

6. “Obstetric fistula can be explained to result from different causes. These holes in the tissue wall between the vagina and bladder and/or rectum are most prevalent in resource‐poor countries, attributable to prolonged obstructed labour and absent or inaccessible remedial prenatal services. Obstructed labour is often due to small pelvic size, resulting from women’s youth and premature childbearing and/or malnutrition. Poverty at national health‐service and family levels often predisposes pregnant populations to suffer high rates of fistula. Global estimates showing up to 100,000 new cases each year and 2 million affected girls and women are probably gross underestimates. Fistula devastates lives of sufferers, who are often expelled by husbands and become isolated from their families and communities. Failures of states to provide prenatal preventive care (including medically indicated caesarean deliveries) and timely fistula repair violate women’s internationally recognized human rights, especially to healthcare in general and reproductive healthcare in particular.” [5]

7. Women usually suffer from an obstetric fistula when they give birth away from a health centre[6]; this means there is no record of it. It is also thought that many women living with fistula do not report it later on because of the shame and isolation they experience. This means that even though the northern half of sub-Saharan Africa has been labelled the ‘fistula belt’, there are no solid figures on its prevalence. However, relevant data includes the following: “The incontinence prevalence rate of 606 per 100 000 women extrapolates to over 10 000 women in Sierra Leone today who could immediately benefit from access to urogynecological care”[7]

8. “While accurate data on the prevalence of obstetric fistula in Sierra Leone has been challenging, anecdotal evidence and initial modelling projections, estimate that about 2,496 women are living with obstetric fistula in the country.”[8] According to the Global Fistula Hub about 176 (average rate) repair operations are carried out in a year in Sierra Leone.[9] At this rate it would take fourteen years to complete the backlog of existing cases, not allowing for additional cases over the coming years. This would mean that many women have a life of misery ahead of them for many years to come. And it provides another good reason to address the issue from a human rights perspective.

Recommendation to the state

  • Address with comprehensive and effective measures and evaluation mechanisms the neglected situation of women in the country, focussing on the human rights of those living with Obstetric Fistula.

Poverty.

9. Extreme poverty has been identified and accepted as one of the primary causes of Obstetric Fistula. Countries with poor road infrastructures, under-resourced health facilities and large rural populations in Africa and South Asia are the places where obstetric fistula is most prevalent. A majority of those living in poverty are women.

10. “Most women who experience obstetric fistula are from poverty-stricken families, lack education, do not understand the necessity of regular antenatal check-ups, and cannot afford antenatal and delivery care in health centres, and therefore decide upon home delivery, to seek care at health centres when complications arise, and incur higher complication associated costs placing both themselves and their new-borns at mortal risk. To meet these costs, women and their families sell property, household goods, cattle, and crops.” [10]

11. “Poverty greatly hinders women’s access to obstetric fistula repair; its effect is compounded by low socio-economic status and level of education, rural residence, lack of prenatal care, and early marriage [11], [12]. A woman living with an unrepaired fistula experiences ostracism, stigma, shame, and partner rejection, is often shunned by her community, in addition to physical consequences such as fetid smell, frequent pelvic or urinary infections, painful genital ulcerations, thigh inflammation from constant wetness, infertility, leg nerve damage, and even early mortality [13]. A recent literature review describes nine direct types of barriers to accessing fistula repair: psychosocial, social, political, financial, along with awareness, transportation, facility, and care quality [14]. Of these nine barriers, financial (85 out of 137 articles) and transportation (69 out of 137 articles) are frequently cited for delayed fistula care—or lack thereof.”[15] Opportunity cost or income loss is one of the results of this condition and lead into even deeper poverty.

Recommendation to the state

  • the government work in a united manner and across multiple sectors to prevent an increase in the prevalence of obstetric fistula by improving the lives and livelihoods of women.

Early pregnancies as a result of poverty

12. Poverty is the main underlying cause of the prolonged, obstructed labour which results in obstetric fistula, due to its association with poor health and nutrition, stunted growth, limited access to health care, illiteracy and links to early marriage and early childbearing. Power imbalance, attitudes to women and gender-based discrimination inform the likelihood of experiencing obstetric fistula. For example, young women may be the last in the family to be fed and may have poor access to nutritious food, resulting in stunting and an under-developed pelvis, complicating childbirth and increasing their vulnerability to obstetric fistula; early age of first childbirth exacerbates this.[16]

13. Young, poorly educated women from rural areas, giving birth to their first child, make up the largest group of women with obstetric fistula, although women who have had several children are also at risk. Child marriage is a global problem with an estimated 12 million girls given out in marriage before they turn 18, some as young as 9. 14 of the 20 countries with the highest rate of child marriage are in Africa. The toxic combination of a young girl having sex, getting pregnant and going through childbirth when her body is not developed enough accounts for at least 25% of known fistula cases.[17]

Education

14. “According to the 2016 Government of Sierra Leone and UNICEF Assessment of the Situation of Out-Of-School Children, nearly three out of every ten out of school girls (28.6%) are excluded from education as a result of teenage pregnancy.”[18]

15. Educating and empowering women and girls is crucial for their well-being and for improving maternal health and preventing fistula. Economic and sociocultural factors that negatively affect women must be addressed, including by educating and engaging men and boys and empowering communities. [19]

16. Less than 40% of girls enrolled in secondary education in 2019.[20] The numbers of girls enrolling in tertiary education is probably much lower. The figures for 2019 are not available. The number of nurses and midwives is at 0.2 per 1000 people in 2016. Meanwhile Ireland’s number is at 16 per 1000 people in 2017. [21] All of this indicates that there are very few qualified midwives available to work in rural areas. To provide the necessary health care for pregnant women during pregnancy and at child-birth there is a need to increase the number of qualified midwives.

17. In the year 2019 “Forty-nine midwives graduated from the National School of Midwifery in Freetown as part of UNFPA’s mission to contribute to the reduction of maternal mortality in the country.” [22]

Recommendations to the state

  • increase the number of candidates for midwifery training by 25% over the next several years, until there are sufficient qualified midwives to serve all the rural areas of the country.
  • recruit these newly qualified midwives to work in the remote areas of the country with a special focus on the prevention of obstetric fistula.
  • the government, beginning in the remote and rural areas, renew and expand all current awareness programmes on the causes and consequences of the devastating condition of obstetric fistula, emphasizing the human rights dimensions of the issue.

Access to Health Care

18. Obstetric fistula, severe maternal morbidity because of prolonged obstructed labour without the mother’s having timely access to an emergency caesarean section, is fully preventable when women and girls have access to high-quality and comprehensive health services.[23]

19. Owing to inequities in their access to health care, many women suffer from unintended pregnancy, maternal death and disability, sexually transmitted infections, including HIV, and cervical cancer.

20. Sierra Leone is an extremely poor country, known to be one of the worst places to be pregnant. However, it is taking steps to improve the lives of pregnant women, with measures like the Free Healthcare Initiative. Slowly, conditions for pregnant women are improving.

There is only one dedicated Health facility that caters for women with an Obstetric Fistula. This facility, is in the capital, Freetown, while the rural areas where many people live are neglected.

Recommendation to the state

  • provide Health Centres in all remote rural areas of the country with qualified midwives and well equipped so as to provide the best possible antenatal advice and care.

Social and economic consequences

21. “The prevalence of obstetric fistulas, the lack of provision for their timely repair, the suffering of untreated women and the stigmatization of both untreated and sometimes treated women represent gross violations of human dignity, and of the legally recognized human rights that serve to protect women’s dignity. In social terms, the burden of obstetric fistulas in much of the developing world arises from early marriage and childbearing before a young girl’s pelvis is adequately developed, and lack of women’s prenatal and obstetric care due to such causes as poverty and residence in rural or remote areas. Lack of care of women in need may be due to the low political priority countries give to the supply of healthcare services, or to the risks of pregnancy complications that young girls and adolescents bear.”[24]

22. “Fistula is considered a “social calamity” [25]and women with obstetric fistula are often ostracized by their husbands, families, and communities. The condition is often considered a sexually transmitted disease and viewed as a punishment from God. Most women with fistulas report disturbed socio-psycho-sexual lives and are usually deserted by their husbands.” [26]

Recommendation to the state

  • put in place educational, psychological and social programmes for women to enable them to take up employment and overcome the stigma and discrimination associated with the condition of Obstetric Fistula.

Disabilities.

23. There are compelling reasons to consider obstetric fistula as an impairment which results in disability. [27]These impairments include, bowel incontinence, mobility impairments, psychosocial impairments related to rejection, stigma and discrimination[28]. These result from barriers in society, such as, attitudes, lack of affordable maternity care within easy reach of where they live, lack of education or information in appropriate formats and are exacerbated by interaction with more barriers (for example, lack of medical and psychosocial services, lack of information, community attitudes, often resulting in divorce and/or lack of access to children.  All too often, the outcome is banishment from community life, poverty, malnutrition, unemployment, denial of access to public services, vulnerability to violence and abuse.  In many instances these are the documented consequences of obstetric fistula in the 21st century.

Recommendations to the state

  • develop and disseminate an educational package to inform boys and girls in schools and colleges and in society about the rights of all women, about fistula and the causes of it, in order to eliminate this preventable condition.
  • develop an appropriate information tool to inform adult men and women about women’s rights with a view to reduce the existing level of discrimination against women in society.

UN General Assembly.

24. Since 2006 there have been at least six resolutions at the UN General Assembly on Obstetric Fistula.[29] And there have been as many reports prepared by the Secretary General.[30] Over time, these reports have called for National Strategies to eliminate this devastating condition. Despite having a National Strategy, and costed, time-bound operational plans[31] Sierra Leone has failed to reduce the prevalence of Obstetric Fistula in the country. This only highlights the lack of Evaluation, accountability and transparency in these plans.

Recommendations to the state

  • put in place effective measures to oversee the implementation of the National Strategy for the elimination of Obstetric Fistula.
  • use a human rights based approach as it seeks to protect the dignity of all women and to prevent Obstetric Fistula having a negative impact on the lives of women.

Conditions in Prisons

25. In its 2016 review Sierra Leone accepted recommendations reducing pre-trial detention, conditions and overcrowding in prisons (111.143, Switzerland); (111.144 United Kingdom); (111-145, Egypt); (111.146, USA),  however despite some progress in reducing numbers, many detainees remain in detention while awaiting charges, trials or completion of their trials. Conditions in prisons also continue to be harsh and potentially life-threatening due to food shortages, overcrowding, physical abuse, lack of clean and safe drinking water, inadequate sanitary conditions and a lack of medical care for inmates.

Recommendation to the state

  • Increase its efforts to improve prison conditions by reducing the length of pre-trial detention, by considering alternatives to detention for minor offences and by the allocation of greater resources.

Corruption

26. In its 2016 review Sierra Leone accepted a recommendation relating to the need to address corruption (111.60, Morocco). Nevertheless, despite some improvement corruption continues to be widespread in Sierra Leone. Transparency International’s Corruption Perception Index has ranked Sierra Leone 119th out of 179 total countries.[32] According to the anti-corruption Commission of Sierra Leone, in 2020 there has been an increase in the proportion of citizens who say they paid bribes for medical care and identity documents, and to avoid problems with the police compared to 2018, and only 28% of the population say they can report corruption without fear of the risk of retaliation.[33]

Recommendation to the state

  • Maintain its efforts to address corruption, particularly in regard to police and medical services.

[1] https://upr-info-database.uwazi.io/en/library/table/?q=(allAggregations:!f,filters:(cycle:(values:!(%273eec3a87-0825-4a8f-a37d-6ca7b03715e4%27)),issues:(values:!(e3a4a718-bc47-4f4f-a00c-60a40d68598a)),response:(values:!(%2734b4d35c-8157-40cf-a42f-c3cd7353d692%27)),state_under_review:(values:!(msb6i1xc7la))),from:0,includeUnpublished:!f,limit:30,order:desc,sort:_score,types:!(%275d8ce04361cde0408222e9a8%27),unpublished:!f)

[2] https://africa.unwomen.org/en/news-and-events/stories/2017/02/sierra-leone-steps-it-up-for-gender-equality

[3] https://esaro.unfpa.org/en/topics/obstetric-fistula

[4] UNFPA: OBSTETRIC FISTULA – NEEDS ASSESSMENT REPORT: FINDINGS FROM NINE AFRICAN COUNTRIES; https://www.unfpa.org/sites/default/files/pub-pdf/fistula-needs-assessment.pdf

[5] Cook RJ, Dickens BM, Syed S. Obstetric fistula: the challenge to human rights. Int J Gynaecol Obstet. 2004 Oct;87(1):72-7. doi: 10.1016/j.ijgo.2004.07.005. PMID: 15464787.

[6] UNFPA – When Childbirth Harms: Obstetric Fistula: https://www.unfpa.org/sites/default/files/resource-pdf/EN-SRH%20fact%20sheet-Fistula.pdf

[7] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4077972/

[8] https://sierraleone.unfpa.org/en/topics/obstetric-fistula-4

[9] https://www.globalfistulahub.org/

[10] “Poverty is the big thing”: exploring financial, transportation, and opportunity costs associated with fistula management and repair in Nigeria and Uganda

Kaji Tamanna Keya, Pooja Sripad, Emmanuel Nwala, Charlotte E. Warren

Int J Equity Health. 2018; 17: 70. Published online 2018 Jun 1. doi: 10.1186/s12939-018-0777-1

[11] Bach R, Warren C, Baker Z, Bellows B. Barriers to Obstetric Fistula Treatment in Low-income Countries: A Systematic Review. Trop Med Int Health. Doi: https://doi.org/10.1111/tmi.12893. Accepted in 16 May 2017.

[12] Zheng AX, Anderson FWJ. Obstetric fistula in low-income countries. International Journal of Gynaecology and Obstetrics: The Official Organ of the International Federation of Gynaecology and Obstetrics. 2009;104(2):85–9. https://doi.org/10.1016/j.ijgo.2008.09.011.

[13] 3. Human Rights Watch. “I Am Not Dead, But I Am Not Living,” Barriers to Fistula Prevention and Treatment in Kenya. 2010. 1–56432–660-8:

[14] Bach R, Warren C, Baker Z, Bellows B

[15] “Kaji Tamanna Keya, Pooja Sripad, Emmanuel Nwala, Charlotte E. Warren

[16] Browning A, Mbise F, Foden P. The effect of early pregnancy on the formation of obstetric fistula. Int J Gynaecol Obstet. 2017 Sep;138(3):288-292. doi: 10.1002/ijgo.12228. Epub 2017 Jun 30. PMID: 28581683.

[17] https://www.girlsnotbrides.org/fistula-a-silent-tragedy-for-child-brides/

[18] Government of Sierra Leone; Ministry of Education, Science and Technology; Education Sector Plan from 2018-2020; https://www.globalpartnership.org/sites/default/files/2018-10-sierra-leone-esp.pdf

[19] Ibid..

[20] http://data.un.org/en/iso/sl.html

[21] https://data.worldbank.org/indicator/SH.MED.NUMW.P3?locations=SL

[22]UNFPA:  https://sierraleone.unfpa.org/en/news/newly-graduated-midwives-contribute-reducing-maternal-mortality-sierra-leone

[23] Intensifying efforts to end obstetric fistula within a generation Report of the Secretary-General 2018, A/73/285

[24] International Journal of Gynecology and Obstetrics (2004) 87, 72—77

[25] Harrison KA. Obstetric fistula: one social calamity too many. Br J Obstet Gynaecol1983;90(5):385-6;

[26] International Journal of Gynaecology and Obstetrics (2007)99, 510-515Social and economic consequences of obstetric fistula: Life changed forever? S. Ahmed *, S.A. Holtz

[27] CRPD.

[28] Report submitted to the Special Rapporteur on Health at the Office of the High Commissioner for

Human Rights in Geneva, May 2017; https://mmmworldwide.org/images/PDF/Statement%20human%20rights%20obs%20fistula%20May%202017%20for%20e-news-website.pdf

[29]  ; A/RES/62/138 (2007) ; A/RES/63/158 (2008); A/RES/65/188 (2010); A/RES/67/147 (2012); A/RES/69/148 (2014);  A/RES/71/169 (2016); A/RES/73/169 (2018)

[30] A/63/222  (2008); A/65/268 (2010); A/67/258 (2012); A/69/256 (2014); A/71/306 (2016); A/73/285 (2018)

[31]Intensifying efforts to end obstetric fistula within a generation Report of the Secretary-General; A/73/285 (2018)

[32] https://www.transparency.org/en/countries/sierra-leone

[33] https://www.anticorruption.gov.sl/blog/anti-corruption-commission-sl-news-room-1/post/afro-barometer-report-2020-confirms-reduction-in-corruption-prevalence-in-sierra-leone-from-70-in-2015-to-lowest-ever-percentum-of-40-in-2020-347