Prevalence of uterine prolapse amongst gynecology opd patients in tribhuvan university teaching hospital in nepal and its socio-cultural determinants


Reproductive Rights Advocacy
Alliance Malaysia (RRAAM);
Federation of Reproductive Health
Associations Malaysia (FRHAM).
Edited by Rashidah Abdullah

ICPD 15 Monitoring and Advocacy on Sexual
Reproductive Health and Rights (SRHR)
Increasing Access to the Reproductive Right to Contraceptive
Information and Services, SRHR Education for Youth and Legal
Abortion (2009)
Edited by: Rashidah Abdullah
Country Report of Malaysia: NGO Perspectives
Federation of Reproductive Health Associations, Malaysia Citation Format: Abdullah, R. (2009). Increasing Access to the Reproductive Right to Contraceptive Information and Services, SRHR Education for Youth and Legal Abortion. Kuala Lumpur, Malaysia: Asian-Pacific Resource and Research Centre for Women (ARROW) TABLE OF CONTENTS
1.0 Introduction 1.1 ICPD 15 Monitoring and Advocacy 1.2 Malaysia's Progress in Sexual and Reproductive 6 Health and Rights 1.2.1 Economic and Social Development 1.2.2 Reproductive Health 1.2.4 Sexual Health and Sexual Rights 1.2.5 Women's Rights 1.2.6 NGO Participation in Planning, Monitoring and Evaluation of SRHR Policies and Plans 2.1 Research Questions 4.0 Findings of the Study 4.1 Barriers to Increasing Contraceptive Used and 12 Decreasing Unmet Need 4.1.1 Discussion of Findings 4.1.2 What Needs to be Done, by Whom and When 16 4.2 Unwanted Pregnancies and Youth Access to Contraceptive Services and Information 4.2.1 Discussion of Findings 4.2.2 What Needs to be Done, by Whom and When 20 4.3 Women's accessibility to legal abortion services and improvement of post abortion counselling and 20 providers' training in abortion 4.3.1 Discussion of Findings 4.3.2 What Needs to be Done, by Whom and When 26 5.0 Conclusion and Recommendations 5.1 General policy and Advocacy Implications 5.2 What needs to be done, by whom and when ACRONYMS
Asian-Pacific Resource and Research Centre for Women All Women's Action Society, Malaysia Convention On All Forms Of Elimination of Discrimination Against Women Contraceptive Prevalence Rate Federation of Reproductive Health Associations Malaysia International Conference on Population and Development Lembaga Penduduk dan Pembangunan Keluarga Negara [the National Population and Family Development Board] Joint Action Group on Gender Equality Malaysian AIDs Council Millennium Development Goals Malaysian Medical Association Maternal Mortality Rate Malaysian NGO Coordinating Committee on Reproductive Health Ministry of Education Ministry of Health Ministry of Women, Family and Community Development Malaysian Population and Family Survey National Council of Women's Organizations Non Governmental Organisations Obstetrics and Gynaecology One Stop Crisis Centre Programme of Action [ of the IPCD] Reproductive Rights Advocacy Alliance Malaysia reproductive health Sisters In Islam Sexual and reproductive health and rights Universiti Kebangsaan Malaysia (National University of Malaysia) Universiti Malaya (University of Malaya) United Nations Population Fund Universiti Sains Malaysia (Science University of Malaysia) Violence Against Women Women Aid Organization Malaysia Women's Centre for Change World Health Organization This report is the joint effort of the Federation of Reproductive Health Associations Malaysia (FRHAM) and the Reproductive Rights Advocacy Alliance Malaysia (RRAAM) as country partners of the Asian and Pacific Resource and Research Centre (ARROW) in the ARROW ICPD 15 Monitoring and Advocacy of SRHR project. The report is coordinated by Ms Rashidah Abdullah, under the management of the FRHAM–RRAAM ICPD 15 Working Group Co, chaired by Assoc. Prof. Dr Mary Huang, Hon. Secretary General, FRHAM and Dr SP Choong, RRAAM. The members also include Dr Kamaruzaman Ali, Chairperson, Ms Mary Pang, Executive Director and Assoc. Prof. Dr Wong Yut Lin, Dr Fathilah Kamaludin and Ms. Rozana Isa of RRAAM. The Working Group gave substantial input into the report, especially, the recommendations and support and guidance. We extend our gratitude to the paper presenters of the FRHAM–RRAAM in Increasing Access to the Reproductive Right to Contraceptive Information and Services; Progress at ICPD 15 on October 2008, whose evidence forms the core of this report. They are Associate Prof Tey Nai Peng; Dr Mymoon Alias, MOH; Dr Kamaruzaman Ali, FRHAM; Dr Komathy Thiagarajan, LPPKN; Ms Tan Huey Ning, MOE; Prof Dr. Sarinah Low; Dr Kanagalingam, Pink Triangle; Assoc. Prof. Dr Wong Yut Lin; and the RRAAM team. Inputs as discussants from Prof. Datin Dr Rashidah Shuib, Assoc. Prof. Harlina Haliza Hj Siraj as well as Ms Kuek Yen Sim, Ms Thilaga Sulathireh, Ms Tan Sok Teng and Mr Yeo Jason as youth representatives are appreciated. Special thanks go to Assoc Prof. Tey Nai Peng for preparing a comprehensive written paper on contraceptive use based on data from the unpublished MPFS 2004 as well as for his comments on the draft report and to LPPKN and EPU for allowing the data to be used. Many thanks to all the Consultation participants for their insightful recommendations, which have provided the direction for what needs to be done, by whom and when and to MsYasmin Masidi the rapporteur for capturing this in the Consultation report. We would like to extend our heartfelt appreciation to Dato Aminah bt Abdul Rahman, Director General, and Dr Norliza Ahmad, Director Human Reproductive Division, of LPPKN and Dr Hjh Safurah Hj Jaafar, Director and Dr Mymoon Alias, Deputy Director, of the Family Health Development Division for agreeing to be interviewed as well as Ministry of Education officials for their We are indeed thankful to the 12 FPAs for taking the time to complete the Questionnaire and to read the first draft of the report. We are grateful for discussion prior to the report as well as thoughtful comments on the draft report from Ms. Yeoh Yeok Kim, Assistant Representative, UNFPA. Many thanks to the FRHAM staff team headed by Ms Mary Pang, especially, in their assistance in document and data collection, and administrative assistance from Ms Khatijah Mohd. Baki, RRAAM and copy editing by Ms Yasmin Masidi. To the ARROW staff led by Ms Saira Shameen, Executive Director and the ICPD 15 team of Ms Sivananthi Thanenthiran, Ms Phan Thi Uyen and Ms Sai Jyothirmai Racherla, many thanks for your guidance in strategically steering this project as well as for the technical assistance and support. FRHAM and RRAAM are very grateful for the funding to ARROW and partners from the Ford Foundation New York, in particular, Ms Barbara Klugman. RRAAM also thanks Ipas very much for contributing to the costs of the report and Ms Leila Hessini of Ipas for her support. Finally, we thank the whole of FRHAM and RRAAM, in general, for agreeing to take on this project, to produce this report, and for providing additional financial and human resource support. The FRHAM—RRAAM ICPD 15 Working ICPD 15 Monitoring and Advocacy
The Malaysian NGO Report for ICPD 15 is one of 12 country reports in a regional ICPD 15 monitoring and advocacy project on sexual and reproductive health and rights (SRHR) led by the Asian and Pacific Resource and Research Centre (ARROW).The project's goal is to contribute to an improved policy environment in the 12 countries and the realisation of comprehensive, affordable and gender-sensitive SRHR services, particularly for poor and marginalized women. Fifteen years have passed since the historic International Conference on Population and Development (ICPD) 1994 was envisioned in Cairo and agreed to by governments, NGOs and UN agencies including the Government of Malaysia. The document by the ICPD Programme of Action still inspires and guides NGOs. This is because it was based on a fresh paradigm of commitment to: human rights; sustainable development; reproductive rights; safe sexuality; women's equality and empowerment; and strengthened government partnership with NGOs. There were clear insights on what needed to be achieved and why, and agreements on what action had to be taken. The Federation of Reproductive Health Associations (FRHAM) and the Reproductive Advocacy Alliance Malaysia (RRAAM), newly established in 2007, are joint country partners in this third ARROW ICPD monitoring project. FRHAM was the ARROW partner for the ICPD 10 Regional Project and the NGO Focal point for ICPD 5. Instead of monitoring a plethora of indicators as in past ICPD projects, ARROW partners are focusing on one SRHR ICPD issue which critically needs to be addressed. FRHAM and RRAAM chose the low and stagnated use of contraception for 20 years, as found by the Malaysian Population and Family Survey (MPFS) 2004. Related to this are the issues of increased reports of abandoned babies and a perceived increase in unwanted pregnancies of young people; a stalemate in the planned implementation of a revised sex education curriculum in secondary schools; and restricted access of women to legal abortion services despite a progressive law. The report is structured according to these three issues. For each issue, findings are reported in relation to the ICPD agreements, discussed, and then specific actions needed to be taken are stated. General discussion on policy and advocacy implications concludes the report. These specific issues are first examined within the overall context of Malaysia's progress in the ICPD sexual and reproductive health and rights agreements. Malaysia's Progress in Sexual and Reproductive Health and Rights
1.2.1 Economic and Social Development
In 2008, 27.17 (Year Book of Statistics Malaysia, 2007) million Malaysians in a modern nation state celebrated 50 years of independence from British colonial rule as well as successful socio-economic development. When Malaysia was formed in 1963, it had a small rural based population of nine million people (LPPKN, 2003), an agricultural economy, a high poverty level of around 50% and a high maternal mortality rate. By 2007, most people lived in urban areas, poverty was only 3.6%, maternal mortality a low 20 deaths per 100,000 live births, and both women and men were well-educated (Malaysia country report, 2008). 1.2.2 Reproductive Health (RH)
Malaysia had a head start on the Cairo agenda in 1994, with already a low rate of maternal mortality of 59 deaths per 100,000 live births, a broad reproductive health programme, and a well established and funded health system. Good economic growth rates between 5% and 7% allowed continued investment in public health which by 2007, meant that 85% of people had access to free health services within five kilometres from their residence (Mymoon, 2008). There are no problems in accessing affordable maternal health services for married Malaysian citizens and Malaysia is a model for other countries in Asia. For women who are migrants (particularly those unregistered), foreign workers (especially domestic workers whose contracts do not allow them to be pregnant even when married), refugees, and unmarried pregnant women, however, there are access problems connected to social stigma, cost and citizenship. Women's access to contraceptive use, breast screening and cervical cancer screening services have lagged behind maternal care. Only 48% of married women are using contraception, only 50% of women had a pap smear in the three years prior to the 2004 MPFS survey and only 53% had ever had a breast examination in a clinic or hospital (Data from MPFS 2004 survey). Although cervical cancer incidence has declined, breast cancer incidence has not and the incidence of HIV/AIDS continues to rise for women. Legal abortion according to the full extent of the law is difficult to access in government hospitals. This data shows that aspects of RH which involve addressing the cultural sensitivities of the body, sexuality, gender, religion and morality have been harder to address than maternal health which has fewer of these complexities. HIV/AIDS
Malaysia has achieved all of the eight Millennium Development Goals except the sixth goal on HIV/AIDS, which is targeted to halt by 2015 followed by the start of the reversal of the spread of HIV/AIDS (UNDP, 2005). At the time of the ICPD, there were only 3,390 people with HIV and 105 people with AIDS in Malaysia. The total number of people with the infection as at June 2008 has increased to 82,704, 14,133 people now have AIDS and there have been 10,873 AIDS-related deaths since 1986 (MAC, 2008). Although male injecting drug users remains the dominant means of HIV transmission, by 2007 almost one-third of new HIV infections were due to heterosexual relations. New HIV infections for men have been declining since 2003, but the number of women infected has been steadily rising from 5.02 % among total HIV cases in 1997 to 16.3% in 2007 or two additional women a day (MOH and UNICEF, 2007). HIV/AIDS has become a priority development and RH issue of the government, NGOs and UNDP. A government National Strategic Plan (2006-2010) and a Malaysian Aids Council Strategic Plan (2008 to 2015) has been developed, and RM 500 million has been allocated under the 9th Malaysia Plan (UNICEF and MOH, 2007).With the resources and strategy now in place, the issues of sexuality, sexual rights, women's rights, gender issues and condom use are the biggest challenges to reducing the epidemic. 1.2.4 Sexual Health and Sexual Rights
UNICEF and the MOH emphasise that in order to have a more effective HIV prevention: "[i]nstitutional and social denial that sexual behaviour of young men and women actually takes place outside of marriage" and "sensitivities surrounding the introduction of sexual reproductive health education in schools" need to be addressed (MOH and UNICEF, 2007, pg 87).The key gender issues here are sexuality and sexual rights. Of specific importance within this, is women's ability to exercise their right to refuse sex if their partner has HIV/AIDS or is known to have multiple sexual partners and yet does not agree to use the condom for protection and women's lack of power to negotiate with men to use the condom. For Muslim women, this debate is still in progress, as married Muslim women's right to refuse sex and demand safe and consensual sexual relations, has not been firmly established as a right. Sexual health and sexuality needs and rights have begun to be more openly addressed in the last 10 years, due to the need to address sexuality in order to combat HIV/AIDS, but there is a long way to go including attitudinal, institutional and law reform. Sexual practices for example, like oral sex and anal sex, which are the reality for both heterosexual and homosexual relationships, are offences in the colonially inherited Penal Code punishable by imprisonment (Penal Code, 2006) and several prominent people have been charged since ICPD. Singapore eliminated this clause from their Penal Code in 2007. Muslim transsexuals have also been charged for indecent dressing under the Shariah Offences Act in an increase of what NGOs call "moral policing" (Sisters In Islam, 2008). Related to this, zealous Muslim religious department officials work hard to charge people with sexual offences like premarital sex, extra-marital sex and close proximity [khalwat]. There is need for acknowledging that sexual behaviour begins earlier now for young people, and that increasingly more people engage in sex before they are married, as well as perhaps after marriage with other partners. Diverse sexual practices and sexualities also need to be accepted as the reality. Heterosexual sex is one form but there are also men who have sex with men, men who have sex with both men and women, women who have sex with women, as well as men who prefer to identify themselves as women (transsexuals). An understanding of social realities and sexual rights in a humanistic and professional way in a multicultural society rather than a judgemental and moralistic frame needs to be developed urgently. 1.2.5 Women's Rights
Women's rights to gender equality and empowerment have been more understood and accepted than sexual and RH rights, due to strong advocacy from women's NGOs and the impact of the 1995 World Conference on Women in Beijing. There has been definite progress in legal equality since the ICPD. The Federal Constitution now includes the clause that there can be no discrimination on the basis of gender. There have been improvements in laws to either eliminate discrimination or provide better protection such as the Domestic Violence Act (1994), the Sexual Harassment Code (1999) and amendments to the Guardianship of Infants Act (1999). Muslim women however, whilst also benefiting from this civil legal reform, have experienced retrogressive amendments to the Muslim family law in the mid-1990s including making polygamy easier for men. Gender inequality attitudes and practices, which still prevail in the family and society, are key indicators on the continuous high incidence of violence against women despite the Domestic Violence Act of 1994, a strengthened rape law and the increased availability of gender sensitive police, hospital services and women's crisis services by the NGOs and government. Evidence of this is that the incidence of violence against women (in all the forms of domestic violence, rape, incest, sexual molestation and sexual harassment), has not reduced and there is an increasing trend in rape. For example in 2004, there were 1,765 rapes reported to the police compared to 1,217 in 2000 and the majority were girls and young women under 18 years of age (WHO Kobe Centre, 2006). Such figures are globally estimated to represent only 10% of actual incidents, so it is likely that there are about 17,000 rape incidents per year. Outcomes of coerced sex, rape and incest include unwanted pregnancies, unsafe abortion, STDs and HIV and psychological trauma, all of which are potentially very disempowering and limit life choices, especially for young women. The education of girls and young women and men in sexual rights, gender equality, pregnancy, protection from unwanted pregnancy and HIV and STDs is therefore urgent. However, sex education has been delayed in both the school curriculum and youth national service programme despite the fact that sex education modules have been prepared and are ready for implementation. The SRHR aspects of the One Stop Crisis Centres [OSCC] for gender based violence survivors in the Accident and Emergency Departments of all General Hospitals, heralded as a model when first launched in the early 1990s, need urgent attention from women's NGOs and the MOH. For many rape and incest survivors, emergency contraception is not routinely available, referral for abortion for unwanted pregnancies depends on the views of the Head of the O and G Department and there is little follow up to identify and treat HIV and other infections (discussion with RRAAM members after the OSCC Seminar of the Women's Centre For Change in Penang, 5th May 2009). In addition, it seems that apart from the initial medical assessment, little is done to support the emotional well being of these women. Women are thus not accessing their sexual and reproductive rights and health rights as planned through these services. Malaysian women's annual deaths due to pregnancy, childbirth, unsafe abortion, reproductive cancers, unwanted pregnancies and gender based violence are comparatively lesser than AIDS-related deaths. However the morbidity, mental suffering and restricted life choices of women (especially young women, poor women and marginalized women) due to unwanted pregnancies, having more children than they desire, and rape, is tremendous. The tragedy is that this morbidity and suffering cannot be calculated as clearly as mortality. Women have the need and right for all their SRHR needs to be equally addressed through high quality gender-sensitive SRHR services as agreed in the UN Cairo and Beijing conferences as a critical component of their health, well-being and empowerment. 1.2.6 NGO Participation in Planning, Monitoring and Evaluation of SRHR
Policies and Plans
NGOs have increasingly been invited to dialogues with the Ministry of Women and Family Development and the Ministry of Health since the Cairo and Beijing conferences. These ministries and the Ministry of Education have worked closely with NGOs on the development of curricula including SRHR for students as has the MOH in the development of a National Adolescent Plan of Action 2006-2020. The UNFPA continues to consult NGOs in the development of its country programme. However, NGO roles overall remain advisory rather than decision- making as agreed in ICPD. Furthermore, selected NGOs are invited to participate in some cases, rather than diverse and more critical NGOs. The National Family Development and Population Board Act of 1966 requires no more than 10 members to be appointed by the Minister drawn from the fields of commerce, labour, education, social services and from professions. The two NGOs on the Board in 2006 were FRHAM and The Older Persons Association and the rest of the members listed under NGOs including the company, Focus On The Family, were individuals working in government and the private sector (Annual Report, LPPKN, 2006). There are now a number of coalitions and alliances which need to be included in related SRHR structures, policy and programme decisions. Apart from FRHAM and NCWO, which were set up in the 1960s, these include the Malaysian Aids Council, Joint Action Group on Gender Equality (JAG), the Malaysian NGO Coordinating Committee on Reproductive Health (MNCCRH) and the Reproductive Rights Advocacy Alliance of Malaysia (RRAAM), which are new in the last decade, are very relevant for the government and the UN to better address SRHR issues. OBJECTIVES
This country's study aimed to monitor the extent to which the specific ICPD agreements made by the Malaysian government have been achieved in the areas a) Reducing unwanted pregnancies, the unmet need for contraception, and the barriers to contraceptive use. b) Comprehensive and Rights-based sex education and more available SRHR services for young people. c) Increasing access to legal abortion, decreasing repeat abortions and improving provider training. Research Questions
a) Has people's unmet need for contraception decreased since ICPD? b) Have the barriers to contraceptive use been identified and reduced? c) Why has the contraceptive prevalence rate not increased? d) What do women themselves and clients say about contraceptive use? e) Has the equal sharing of responsibility of men in using contraception and using the condom for protection from HIV and STDs increased? f) What do men themselves say about men's sexual practices and condom use? g) To what extent have reproductive rights been promoted and the quality of contraceptive services been improved? h) Have unwanted pregnancies amongst young people been reduced and are there stronger sex education and service efforts to prevent these? i) What do youth themselves say they want and need? j) Has accessibility of legal abortion services as part of reproductive health services increased? k) Has there been a decrease in repeat abortions and improvement in the quality of post abortion counselling and as well as training of providers? l) What needs to be done, how, by whom and when, in order to better implement the ICPD agreements on sexual and reproductive health and rights? METHODOLOGY
Evidence Gathering Methods
a) A Consultation in October 2008 of 40 strategically chosen stakeholders from universities, NGOs, Parliamentarians, youth and government which focused on key monitoring questions and achievements of indicators in relation to ICPD agreements. Ten evidenced-based papers by the government, NGOs and academics were presented on the indicators and questions for each related ICPD agreement (FRHAM-RRAAM, Report of Consultation, 2008). b) Interviews and discussion with LPPKN, MOH Family Health Division, the Curriculum Development Centre of the Ministry of Education; the Academy of Family Physicians; the Academy of Islam, University of Malaya, and c) Document analysis of reports, policies and publications of the National Population and Family Planning Board (LPPKN), the Malaysian NGO Coordinating Committee on Reproductive Health (MNCCRH), FRHAM, RRAAM, other related NGOs, and academia. d) A questionnaire completed by 12 of the 13 Family Planning Associations. FINDINGS OF THE STUDY
Barriers to Increasing Contraceptive Use and Decreasing Unmet Need
Where there is a gap between contraceptive use and the proportion of individuals expressing a desire to space or limit their families, countries should attempt to close this gap by at least 50 per cent by 2005, 75 per cent by 2010 and 100 per cent by 2015 ." UN General Assembly 1999 (ICPD +5, para. 58). As part of the effort to meet unmet need, seek to identify and remove all the major remaining barriers to the utilization of family planning services (ICPD PoA 7.19). To increase the participation and sharing of responsibility of men in the actual practice of family planning (ICPD PoA 7.14 (e)). Unmet need. The ICPD+ 5 targets of reducing the gap between the individuals
expressing a desire to limit the number of children and not using contraception has not been achieved. In fact, the unmet need for limiting births has substantially increased from 16 % of married women in 1988 to a high level of 24% of women in the 2004 Malaysian Population and Family Survey (Tey, 2008). Stated simply, 24% of married women who said they did not want any more children were not using any kind of contraception in 2004. Women are now wanting fewer children but they have not increased their use of contraceptives to achieve their desire. Women were not asked the question on their desire to space pregnancies and their actual contraceptive use, unlike in the 1988 survey. Only married women were interviewed in the 2004 MPFS survey and unmarried women were excluded. Actual unmet need would thus have been higher as there is data that shows sexual activity and marriage age of young people are Contraceptive use. The extent of unmet need is directly related to contraceptive
use. The Contraceptive Prevalence Rate (CPR) which includes all methods, declined slightly since ICPD from 55 % to 48% of married women of reproductive age using any contraceptive method, back to the 1988 level of 49% (Tey, 2008).Contraceptive use has therefore stagnated for 20 years and is low for a country with Malaysia's level of socio economic development and Human Development Index. The CPR for modern methods has also not increased significantly which is of great concern. Only 32 % of women used a modern method in 2004 compared to 30 % in 1994 and 34% in 1998. Among the states, use of modern methods in 2004 was lowest in Kelantan at only 16%, followed by Terengganu at 19% and the highest was Negri Sembilan at 63 % (Tey, 2008). Malaysian married men's use of the condom in 2004 remained a low 6.9% and vasectomy a minute 0.1% with male methods increasing only slightly since the ICPD. This data excludes condom use for single men, who were not interviewed. Many more women (6.1%) are undergoing sterilization even though the vasectomy procedure is much quicker and easier for men (Tey, 2008). Women thus continue to take most responsibility for contraception and there is no progress towards the ICPD objective of men and women sharing the responsibility for contraception equally. A 2007 UNFPA-funded survey of students, workers, and sex workers found that of the 73% of sexually active men interviewed, only 40% had ever used the condom. The majority of men did not use the condom for their first sexual intercourse or with their primary partner (Wong, 2008). All of the national family planning agencies reported initiatives aimed at increasing men's contraceptive responsibility since the ICPD including employing male staff, and holding men's health clinics and seminars. However, they did not state if there were resulting outcomes in the increasing use of men's contraception at individual, clinic or state levels. Nationally, there has been no impact of these initiatives on men's contraceptive use. Barriers to Increasing Contraceptive Use
Women's perspectives. The reasons women gave in 2004 for not using
contraception are of great concern as "fear of side effects" is a high 26.9 % and this reason has increased compared to 1994. When "medical and health reasons" are added, the total is 32.3% women gave for programme-related reasons. "Husband's objection" as a reason for not using contraception which is an indicator of gender power relations, has also increased from 8% in 1994 to 12.6% in 2004 (Tey, 2008). This is indirectly a programme-related reason too as the programme has been unsuccessful in influencing and educating men on contraceptive use and men's responsibility. Women's "experience of side effects" has remained the highest single reason for discontinuing contraception, increasing in 2004 to 26.5% of the total reasons compared to 22.4 % in 1994 (Tey, 2008). When combined with "discomfort caused by a method", "method failure", and "advised by a health professional", this makes a high total of 44.6% of discontinuation reasons related to dissatisfaction with contraceptive methods. This means that the client confidence level in contraceptive methods is low, indicative of the quality of the information and service programme. Perceptions of Barriers of Other Stakeholders.
The low key family planning policy was given as a major reason for the stagnated and low contraceptive use by LPPKN, MOH and FFPAM Consultation presenters, Consultation participants, interviewees, and LPPKN publications. The family planning service was said to be low priority for time spent on client information and education by health providers compared to other RH services and family planning as a service is not regarded highly. Among the competing RH service interests, family planning is the lowest (RRAAM Negeri Sembilan seminar; Consultation report; interview with MOH). Information and education on contraception through wide community outreach stopped in the late 1970's and this is also attributed as a major reason by researchers (Tey, 2008) as well as LPPKN (LPPKN, n.d.). References have been made in both government and NGO reports that beliefs about Islam and contraception are a factor in the lower use of contraception by Malays (LPPKN, n.d). However there are no up to date research findings on this aspect and there was no agreement of Consultation participants about this factor. Both LPPKN and the Academy of Islam, UM stated that there is clear support from texts and fatwas for the permissibility of contraception for Muslims for spacing pregnancies. This was also the position of Sisters in Islam and the Kelantan Family Planning Association in their publication. All national family planning agencies reported initiatives to continue to improve the quality of care of family planning services including obtaining client feedback. The improvement in the quality of care of family planning programmes would be indicated by an increase in new clients, an increase in continuing clients (i.e. less discontinuance), greater use of effective methods, and an increase in client satisfaction. This data was not presented in the Consultation by any agency. Structural Barriers: the Functioning of State Reproductive Health
Each state has a Reproductive Health Committee led by LPPKN in which the MOH, FPA and LPPKN participate. This committee is the main mechanism for planning, monitoring and evaluating the national family planning programme. Eight of the 12 FPAs reported that this committee has not met at all in three years between 2006 and 2008, 2 FPAs reported one meeting and only 1 FPA reported 2 or 3 meetings (Questionnaire to FPAs). This means that there is no coordinated planning and evaluation of implementing agencies at the state level in order to address barriers and improve performance. Particularly in states in which there is a very low use of any kind of contraception like Kelantan (24.3%) and Terengganu (29.9%), the non-functioning committees are missed opportunities to address programme barriers and contribute to making family planning a low priority, especially for LPPKN as the lead agency. Reproductive Rights
ICPD Agreement on Reproductive Rights The promotion of the responsible exercise of these rights (reproductive rights) should be the fundamental basis of government and community-supported policies and programmes in the area of reproductive health, including family planning (ICPD PoA, para 7.3). Only FRHAM has included the concept of reproductive rights in the organisation's philosophy, in the objectives of family planning services and in the adoption of a rights based approach in services. The actual components of a rights-based approach were not explained in the FRHAM Consultation presentation nor the extent that this approach has been successfully implemented. In the questionnaire to the FPAs, most responded to the question of "whether they implement a rights based approach in family planning services" very generally (Questionnaire to FPAs, 2008). The MOH says its approach to contraception is a health approach rather than a rights approach with RH as the concept used. They have, however, begun some limited training in reproductive rights for about 25 doctors annually since 2006 following the publication of the WHO training manual on Gender and Rights in Reproductive and Maternal Health. LPPKN did not mention the aspect of reproductive rights in their Consultation presentation. The National Family Planning Programme, which is coordinated by LPPKN, has objectives that do not mention reproductive rights. There is no operationalisation of the concept of reproductive rights in the LPPKN reports examined and the term is included only once in a heading in the LPPKN report on "Implementation of the ICPD PoA in Malaysia" with no corresponding text 4.1.1 Discussion of Findings
The underlying reason for the low priority of family planning services is the continued focus on population and development concerns as in pre-ICPD days rather than adopting the human rights, reproductive rights and women's rights framework of the ICPD POA. The 1984 population policy expressed the economic need for more people as labourers and consumers. As the population size is still growing but at a slower pace than expected and fertility continues to decline, the government may not be worried about population size. In fact, it may be worrying that the decline of the fertility rate is too rapid and that labour will be a greater problem. Now Malaysia needs to recruit international workers and in 2003, foreign workers with permits accounted for 9.5% of the 10 million work force and non-Malaysians made up about six per cent of the work force (LPPKN, The total fertility rate in Peninsular Malaysia had declined to 2.5 children per woman aged 15-49 in 2005, from 3.0 children in 2000 and 3.3 children in 1995. The decline had occurred within all communities. The Chinese and Indian fertility were below replacement fertility, at about 1.8 and 1.9 children per woman respectively, but the Malay fertility rate remained relatively high at 2.9 (Tey, 2008). The rising age for marriage and contraceptive use have contributed to the fertility declination. For example, women aged 30-34 who had never been married had gone up from 6% in 1970 to 14% in 2000(Tey, 2008).It is expected that an increasing number of these women never marry. Women and men were also marrying later at an average age of 25 years for women and 27 for men in 2000. But these factors alone do not explain the whole picture. Tey Nei Peng (2008) comments that the continued decline of fertility despite a puzzling stagnation of contraceptive use for 20 years, may be due to abortion. He contends that it is well known that in countries with a high Human Development Index (HDI), and low contraceptive use such as Japan and Poland, abortion has resulted in the low fertility. WHO explains that abortion rates are highest globally in countries which have low CPR (WHO, 2003). Abortion practice and incidence thus needs much more research attention. The complacency about low contraceptive use due to fertility decline, may be misplaced if a significant number of women are seeking abortions due to lack of confidence in modern contraceptive methods. As access to abortion is restricted, secretive and unaffordable in the private sector for low-income women (see section 4.3 in this report), they are the ones who would be most disadvantaged. From a health perspective, the government may also not see any problems related to the low and stagnated contraceptive use, as maternal mortality continues to decline, women of high medical risk and high parity are successfully being targeted to use contraception, and family planning services are available in all MOH clinics. As LPPKN states in the publication, Implementation of the ICPD- PoA (n.d.): The government does not have a policy to bring about rapid decline in fertility. Instead, it has provided the necessary services for couples to decide on the number and timing of births based on informed decisions. As in other parts of the world, socio economic development has set the impetus for fertility decline in Malaysia (pg. 48). Peoples' need and reproductive right to have accessible and effective contraceptive services in order to meet their desired family size according to their income, social, health and well-being needs as articulated at ICPD, is apparently not yet considered an important human right by the Malaysian government. There was only one reference to unmet need in the LPPKN ICPD 10 publication, as in the following recommendation: Promote greater utilization of reproductive health services including family planning, by stepping up IEC activities and making services more accessible and affordable that will result in greater use of modern and safe methods of contraception and reduce the unmet need for family planning (LPPKN, n.d, pg 58). This recommendation is very pertinent and LPPKN can be asked to what extent were there successful efforts to implement this in the last five years. The total fertility rate is a demographic measure related to population growth and development whereas unmet need indicates individuals' desire for children and is very relevant for human rights. The serious omission of unmet need questions completely in the 1994 MPFS and for spacing births in the 2004 MPFS, is a neglect of the importance of human rights and the IPCD agreements on unmet 4.1.2 What Needs to be Done, by Whom and When
Develop an ICPD National Action Plan
This needs to be developed by the government in partnership with diverse NGOs including women's groups with time frames for specific objectives, for example: • Increasing the Contraceptive Prevalence Rates; • Decreasing unmet need ; and • Immediately identifying priority research for overcoming barriers to contraceptive use identified in the 2004 MPFS. A Paradigm Shift to a Rights Approach
LPPKN, MOWFD and MOH need to immediately adopt the ICPD human rights and reproductive rights concept in population, RH and family planning policies and programmes. This includes free access to information and contraceptive services as a basic right for everyone without exception (e.g. marital status, citizenship, ethnicity or religion). Establish New Indicators
The monitoring and evaluation of RH programmes by MOWFD, LPPKN and MOH need to go beyond mortality, morbidity and demography to include indicators of reproductive rights such as the unmet need for contraception, the extent of access to SRHR information and services, and the extent of access to legal abortion services. Increase Passion and Commitment to Contraceptive Services
The loss of the enthusiasm, passion and effectiveness which family planning programmes had in the 1970's, can only be regained through the effort of the government and FPAs to give contraception and establishing SRHR educational programmes as a higher priority, giving it greater recognition and making more effort in conducting the programmes. More Qualitative Programme Research
Much more in-depth research needs to be done by all agencies and academics to understand and overcome programme weaknesses causing lack of confidence in modern contraceptives and contraceptive drop-outs. Two important areas are how to best educate men so as to reduce their objections and increase their use of male methods and what works best for empowering women to successfully negotiate their sexual rights. Earlier Discussion of MPFS Findings
There needs to be discussion led by LPPKN between MOH, MOWFD, MOE, parliamentarians, researchers, and NGOs nationally and at state levels, on the implications of the findings of the 2004 MPFS. LPPKN needs to provide more information and analysis of the 2004 MPFS findings. For example, the specific reasons husbands do not agree with family planning and the specific reasons for stopping contraception clustered under the large category of "others". Discussion and publication need to be carried out much earlier for future MPFS surveys and other researches so that findings can be quickly utilized to improve programmes. A Strategic Planning State and Needs Approach
Up to date state data on CPR and unmet needs has to be available, analyzed and discussed regularly by state and national level Reproductive Health Committees in order to strategically plan a state and needs approach aimed to increase contraceptive use. Unwanted Pregnancies and Youth Access to Contraceptive Services
and Information.
To address adolescent sexual and reproductive health issues including unwanted pregnancies… (ICPD PoA 7.44). To prevent unwanted pregnancies and to reduce the incidence of high risk pregnancies and morbidity and mortality (ICPD PoA 7.14 a). To make quality family planning services affordable, acceptable and accessible to all who need and want them, while maintaining confidentiality (ICPD PoA 7.14 Innovative programmes must be developed to make information, counselling and services for reproductive health available for adolescents and adult men (ICPD PoA 7.8). Unwanted pregnancies. There appears to be an increasing number of unwanted
pregnancies and abandoned babies reported in the media. These include heart- rending incidents of schoolgirls and factory workers giving birth in toilets, and married women abandoning new-born babies. One baby is abandoned every ten days in the Klang Valley. From 2001 to 2004, the Social Welfare Department recorded 315 cases of abandoned babies, while police statistics revealed 100 cases a year (NST, 5th July 2007). This data is expected to be underreported and a higher incidence is likely. There is no available data to the public on the number of women with unwanted pregnancies seeking refuge in social welfare and NGO homes annually. One centre for women and teenagers run by a Muslim couple in Kuala Lumpur was reported to provide shelter to eighty to one hundred unwed pregnant women and girls in a year, with about forty percent of them being undergraduates (The New Paper, 2004, reported in R. Abdullah and Yut Lin Wong, 2008). Sexuality and marriage age. Young people are becoming increasingly sexually
active before marriage but up to date reliable data is not available for the public. Data from a media survey by LPPKN between 1994 and 1996 quoted by MOH found that about 24% of 13 to 19 year olds had engaged in sexual intercourse and 18.4 % had their first intercourse between the ages of 15 to 18 years (the National Adolescent Health Plan of Action MOH, 2007). There is also an increasing trend of later marriages and not marrying which means a period of ten or more years between some young people beginning sexual activity and marriage. The average age of marriage in the year 2000 was 27 years for men and 25 years for women. Fourteen percent of women aged 30 to 34 years had never married in the year 2000 (LPPKN, 2006). If contraception is not used during these years, there is a high risk of unwanted pregnancy. Contraceptive use and services. There is no data, however, on the extent of use
of contraception by young and unmarried people. This is critical information which needs to be available in order to plan effective programmes. We do know from the 2004 MPFS that a little less than half of the young people aged 13 to 24 had heard of at least one contraceptive method. Despite the prominence of condoms in pharmacies and retail shops, only 1 in 4 young people knew about the method. The rhythm method was mentioned by only two percent of the young people in the survey (Tey, 2008).This shows a huge unmet need for information on contraception. Very limited contraceptive services are discreetly provided for young and unmarried people in government and NGO reproductive health services; "discreetly", meaning this is not openly talked about. The MOH clinics provide contraceptives to unmarried people on a case by case basis for "high-risk young people", who are sexually-active, drug users or HIV positive (MOH, 2007). Nine of the 12 FPAs who responded to the FPA questionnaire also provide contraceptives discreetly. This is definite progress for both government and NGOs in beginning to responding to the contraceptive needs of youth. Most unmarried people are therefore thought to obtain contraceptives from private sector outlets including pharmacies which can legally provide contraceptives irrespective of marital status and not on a restricted case by case basis and retail shops for condoms. Even for married couples, twenty seven percent of current oral contraceptive users obtained the pill from pharmacies in 2004 (Tey, 2008). Education efforts. The implementation of the revised Reproductive Health and
Social Education curriculum for in-school secondary school students which "is designed to provide accurate and up to date knowledge about human sexuality in its biological, psychological, socio cultural and moral dimensions" (Ning, 2008) has been delayed. The curriculum was developed with the assistance of NGOs including FHRAM, AWAM and the Women's Centre for Change over four years, endorsed by religious leaders of all faiths and approved by cabinet in 2006 with a budget allocation of RM 20 million. The curriculum is said to have been delayed due to changes in priority, commitment and political will related to top officials of the MOE (FRHAM-RRAAM Consultation Report, 2008). Implementation of the new component completed in 2008 on "Family and Healthy Lifestyle", for the compulsory National Service education programme for youths aged 18 years who have just completed school, has also been delayed and was not part of the 2009 programme. NGOs such as FRHAM, WAO and AWAM who worked with LPPKN on developing the component, assess that although the allocated hours and content are inadequate to address the actual sexuality components, it does provide a way of reaching adolescents on the importance of gender equality and empowerment and violence against women issues (FRHAM- RRAAM Consultation Report, 2008). The in-school and out of school government curricula promote sexual abstinence as the main method to prevent unwanted pregnancy, whereas the reality is that many young people are increasingly not abstaining from sexual activity. Contraception information is not included in either curriculum. Abstinence can be promoted but education on sexuality, pregnancy, contraception and especially condom use, needs to be also included in order to prevent unwanted pregnancy, 4.2.1 Discussion of Findings
The delayed implementation of the Reproductive Health and Social Education curriculum in secondary schools appears to be related to fears and concerns of top policy-makers. The specific concerns have not been revealed and need to be, especially as the key religious leaders of all faiths have given their approval for implementation as has the cabinet. It would be a tragedy and neglect of young people if concerns were political in nature, related to election concerns. Meanwhile, young people remain critically in need of comprehensive and accurate education to protect themselves from pregnancy, HIV/AIDS, rape, incest and coerced sex. Access to such information is a reproductive and human right. In delaying curricula implementation, this right is not being acknowledged and respected by top policy makers, due to perhaps self-interest. Up to date and congruent research findings on young peoples' knowledge, attitudes and behaviour towards sexuality, unwanted pregnancies, abortion and contraception were not available for this study, and different agencies and academics gave different figures. Without accurate data on which to assess young peoples' needs and plan education and service interventions, ad-hoc planning rather than strategic planning is likely, resulting in less effective outcomes. If reliable national studies have been done, the findings are not available to FRHAM and RRAAM let alone to young people themselves and to the public. For example, the findings of a study of youth sexuality by an academic published in the newspapers several years ago were vigorously disputed by the government as being inaccurate. Difficulty in accepting social reality which may be disturbing to one's religious views and is also politically sensitive, such as the increasing premarital sex and drug use among young people, has been a common denial in modernizing Malaysia, more so apparently for top politicians than for parents and youth themselves. This reluctance to accept reality is speculated to be one of the main reasons that HIV infections and high levels of drug use have not been effectively 4.2.2 What Needs to be Done, by Whom and When
Urgent Implementation of Curricula
Top policy makers of the MOE, MOH, and MOWFD need to work closely together with a strong will to begin implementation of a high-quality Reproductive Health and Social Education curriculum for secondary students in 2009 and the National Service curriculum in 2010. Recognise Sexual Abstinence Alone Doesn't Work
The MOE, MOWFD and MOH need to recognise that the concept of promoting sexual abstinence as a sole method to reduce sexual activity and prevent unwanted pregnancies among young people is not backed up by international studies. Abstinence can be promoted in the curricula but education on sexuality, pregnancy, contraception and especially condom use needs to be also included in order to prevent unwanted pregnancy, HIV and STDs. Strengthen NGO Advocacy, Monitoring and Evaluation
MNCCRH needs to strengthen advocacy efforts including developing a policy brief with evidence and lessons learned on comprehensive sex education including Scandinavia's sex education experience of reducing unwanted pregnancies without a corresponding increase in the sexual activity of young The MNCCRH with the support of other NGO allies needs to promote through convincing policy briefs and dialogues, the need for a holistic, comprehensive, non-moralistic approach to sexuality and RH education for pre-school to out of school youth needs, including vulnerable youth in juvenile homes, refuges for unmarried pregnant women and drug users. Implementation of the new curricula for youth needs the continued involvement of the MNCCRH, women NGOs and the Reproductive Health Committees in regular monitoring and evaluation to ensure the effectiveness of new content on sexuality, VAW and gender equality. Website Strategic Planning
Government and NGOs need to ensure that the youth educational websites they manage have all the SRHR information youth need and are the first sites that appear when the terms sex and pornography are searched by young people (FRHAM-RRAAM 2008 Consultation recommendation from youth themselves). Women's Accessibility to Legal Abortion Services and Improvement
of Post-abortion Counselling and Providers' Training in Abortion
Women who have unwanted pregnancies should have ready access to reliable information and compassionate counselling…. In circumstances where abortion is not against the law, such abortion should be safe. In all cases, women should have access to quality services for the management of complications from abortion. Post abortion counselling, education and family planning services should be offered promptly, which will also help to avoid repeat abortions. (ICPD the right of men and women to other methods of their choice for regulation of fertility which are not against the law… (ICPD PoA 7.2). In circumstances where abortion is not against the law, health systems should train and equip health service providers and should take other measures to ensure that such abortion is safe and accessible. Additional measures should be taken to safeguard women's health." (UN General Assembly ICPD+5, 1999) ….Post abortion counselling, education and family planning services should be offered promptly, which will also help to avoid repeat abortions (ICPD PoA Restricted access in public health services. There is strong anecdotal evidence
of very restricted accessibility of women to legal abortion in several public hospitals in Kuala Lumpur, in Selangor and in a number of other states. Abortions, when they are provided in government hospitals, are usually for medical reasons only including saving the life of the woman and not according to the full extent of the Penal Code which includes physical and mental health Some women who have been raped or survived incest and women with foetuses which have gross brain deformity have been reported to have been refused abortion (RRAAM NGO Seminar Report). In one Kuala Lumpur hospital, an extreme reluctance to perform any kind of legal abortion was reported in 2007. Women whose foetuses were known to be grossly deformed were referred to other government hospitals in which there were doctors who were comfortable with doing abortions. In another Kuala Lumpur hospital, discussion of abortion among staff is not allowed, raped women who want an abortion cannot get access and hospital social workers are not permitted to refer women to the private sector Anecdotal evidence from Women's Aid Organisation, reported from focus group discussion, showed that some low income, young and disadvantaged women have been refused safe, legal and affordable abortion from government hospitals (Shoba, 2007). Eight of the FPAs reported that they do not refer women who requested for abortion to state General Hospital and five gave the reason that the O and G Department does not accept abortion referrals (Questionnaire to FPAs, The One Stop Crisis Centres in general hospitals for survivors of rape and domestic violence, do not routinely refer to the O and G Department when unwanted pregnancy is an outcome. Emergency contraception to prevent unwanted pregnancy is also not routinely provided although the drug is now available for hospital services. These centres were designed together with women's NGOs in the mid-1990s to be women-centred and gender-sensitive but women are not yet able to access their sexual and reproductive rights. Nine FPAs reported that they did not know if the state general hospital provides abortion for pregnant women who have been raped or experienced incest and only one reported the service is available (Questionnaire to FPAs, 2008). Costly and secretive private sector services. Abortion services are available in
the private sector especially in urban GP and specialist clinics, but services are costly, secretive, unregulated and their quality has not been assessed. Ten FPAs refer women who request abortion to private clinics, and report between 1 to 5 doctors on their referral list. Two FPAs do not refer women, the reason of one FPA being that he/she do not know any private doctor who provides the service (Questionnaire to FPAs, 2008). An agency for refugee women reported to RRAAM the difficulty in finding out initially which private sector doctors provide abortion services, and then in actually obtaining the service. The reported cost of an abortion can reach RM 2,000, making the service inaccessible to poor, low-income and young women. An average fee for an early abortion should be around RM 300 (RRAAM, 2007), which shows that some doctors are exploiting the confusion about the legality of abortion. It is not known if accessibility to abortion services in the private sector has increased since the ICPD as services only began to be monitored by RRAAM in The limited accessibility of abortion services contributes to the increasing numbers of reports of abandoned babies in the media, discussed earlier under point 3.2. The reported circumstances of many of these women who had unwanted pregnancies show desperate, isolated and mentally distressed women without social support. Abortion accessibility also affects the life choices and well being of women. It was reported to RRAAM by a research worker working in shelter homes that some unmarried women told her of their mental distress and that they would have preferred to have an abortion than go through with the pregnancy but they did not know where to go (RRAAM, 2007). In government hospitals and many private doctor services, the main abortion method is still the traditional dilation and curettage, which requires anaesthesia and hospitalization, is more costly and carries more risks than the manual vacuum aspiration [MVA] method. MVA is a short outpatient service available globally for 35 years. Medical abortion using Mifepristone (or Methotrexate) and Cytotec has been available globally for over 15 years. Research shows this is the preferred method of women in developed countries but in Malaysia, it is rarely available in private clinics and is not available in government hospitals. Mifepristone is presently manufactured by WHO but is not registered in Malaysia. Abortion methods which are cheaper, more convenient, safer, and in which women have more control as they are less ‘medicalised', are important to increasing accessibility (Choong, 2008). Barriers Restricting Access to Legal Abortion
Legal barriers
The main barrier is misconceptions of doctors, nurses, the media and the public that abortion is not legal. A RRAAM survey found that of 120 doctors and nurses from both the public and private sectors involved in RH services, 43% responded incorrectly about the law (RRAAM, 2007). Women themselves are similarly not well informed. A survey of RH clients who had had a legal abortion in a private clinic, found that 41% did not know the correct legalities on abortion (Kamaluddin, 2008). Even the National Population and Family Development Board (LPPKN) has inaccurately described the law in the LPPKN publication titled, Implementation of the ICPD PoA in Malaysia, reviewed for this report. It incorrectly states that "abortion is allowed only on medical grounds" (LPPKN, n.d., pg. 38). Until 2007, key NGOs had similar inaccuracies in their website or in media statements made until they were informed correctly. The language of the Penal Code on abortion is also confusing as it begins with possible offences in the section titled "miscarriages" and then qualifies these offences with exceptions (Penal Code, clause 312 to 314). Although no doctors have been convicted of abortion offences since the 1989 Penal Code Amendments, which extended permissibility of abortion from saving a woman's life only to when physical and mental health reasons are deemed injurious, there have been a few doctors charged with contravening some aspects. As these cases have had wide media publicity, some doctors are thus afraid of convictions as well as confused about the law. The Malaysian Medical Council Code of Ethics is not up-to-date on the legal status of abortion. This adds to the confusion and uncertainty of doctors about the There have been no initiatives after the progressive amendments to the Penal Code in 1989, until 2007, to educate health providers, women, the media and the public on the up-to-date legal status of abortion. Service barriers
There is evidence that there are unsympathetic and judgemental attitudes of many doctors and nurses on unwanted pregnancies and abortion. When asked the survey question: "What do you think women who are pregnant due to rape should consider doing?", 38% of the 120 doctors and nurses responded that such women should continue the pregnancy and either look after the baby themselves or give it up for adoption rather than consider having an abortion (RRAAM, 2007). There is no MOH policy on provision of abortion services and availability of abortion services was reported to vary according to the views of the Head of the O and G Department in the various hospitals. The hospital requirements of more than one doctor's decision before an abortion is done (even though only one doctor's decision is required by the Penal Code), and the consent of the husband for the procedure are also service barriers (RRAAM, 2008). The ethical issue of the personal religious or other moral beliefs of doctors on abortion influencing their provision of services and referral has been reported to RRAAM as a common barrier within government hospitals, which explains the different practices in the O and G Departments of government general hospitals. The continued media sensationalising of abortion as a moral rather than a health and rights issue, lack of empathy for women needing and entitled to abortion, as well as on-going media statements that abortion is illegal, keeps the public and service providers incorrectly informed. Fifteen per cent of doctors and nurses responded in a survey that the media was the main source of information for them on the legality of abortion (RRAAM, 2008). Decreasing repeat abortions and improving post-abortion counselling and
provider training
No national data on repeat abortions is available. Neither is there reliable data on abortion incidence, and the number and ages of women dying from unsafe abortion. As abortion services are part of the package of RH services, such up-to- date data is essential. In addition, the probable effect of abortion practice on fertility levels, discussed earlier, requires data to be available. There are no known Malaysian studies assessing the availability and quality of post abortion counselling. Medical education curricula for undergraduates in the three public universities of HUKM, USM, and UM are not up-to-date on the legality of abortion. In the first university, the abortion law is being incorrectly taught. In the second university, postgraduate students were reported to be confused about the law. In the third university, the law is understood as allowing abortion for health reasons only, such as when the foetus is deformed. Practical training on abortion is not available for undergraduates due to the very few numbers of abortions being carried out in government hospitals. More content on abortion is in the post graduate medical curriculum and more practical experience available in the provision of abortion services. The situation in the many other private universities is not known but needs to be assessed (FRHAM- RRAAM Consultation Report, 2008). 4.3.1 Discussion of Findings
Neglecting and disrespecting women's needs and reproductive right to access a legal abortion in government health services when their physical and mental health are at risk, is again evidence that the human rights of individuals and the reproductive rights of women are not yet a priority concern of government. Although there is definitely a widespread of the ignorance and confusion about the legal status of abortion, the fact that the law has been amended 20 years ago but is not known to most people, shows insufficient concern for women's needs and rights especially among organisations which advocated for these legal reforms. In fact, there is a case to make on the violation of Malaysian women's reproductive rights to legal abortion services in government hospitals. This violation can be addressed to the CEDAW committee in the 2009 NGO report on Malaysia as well as to the Malaysian Human Rights Commission (RRAAM NGO Seminar Report, 2008). There are many accessibility issues to address in O and G, and One Stop Crisis Centre hospital services as well as in referrals from MOH clinics. However, once the legal status of abortion is widely understood and with the current open attitude of the Family Health Division of MOH and champions among the Heads of O and G Departments, improving service accessibility is possible. For the first time on SRHR issues, women's NGOs and reproductive health NGOs have teamed up under RRAAM with committed medical specialists, lawyers, feminist women's health researchers, the FPAs, the MOH and the MMA to undertake doctors' education in abortion and reproductive rights in all the states in Malaysia. It is critical that medical education curricula and lecturers are correctly informed about the law, the latest abortion methods and the needs and reproductive rights of women. The media also need to be informed urgently as well as the public and women themselves. Unless this is done at the same time as state education seminars, doctors who are misinformed and incorrect in their understanding about the legality of abortion, and do have the competency to provide quality services, will be produced, continually. 4.3.2 What Needs to be Done, by Whom and When
Comprehensive Review and Update of Medical Education Curriculum.
Contraception, abortion and SRHR issues need to have a higher priority in the medical curriculum at all levels for public and private universities. A comprehensive curricula review and revision needs to be undertaken by MOH and • Address the low CPR and barriers to family planning access; • Introduce a reproductive rights and gender framework; • Explain the legality of abortion accurately; • Teach all abortion methods and ensure training practice; • Include empathy training, socio cultural issues and professional ethics. Expansion of MOH Abortion Services
The MOH needs to have a clear policy and practice on the provision of legal abortion services as a core RH service in the O and G Department including referrals from the OSCC, MOH clinics and other agencies, which is in full compliance with the Penal Code and in consonance with women's reproductive rights. Rape and incest survivors, and poor, vulnerable and disadvantaged women, require priority abortion services. Malaysian Medical Code of Ethics
MNCCRH, FRHAM, RRAAM and other NGO allies need to work with the MMA and the O and G Society to ensure that the Malaysian Medical Council Code of Ethics is accurate and clear on the legal status of abortion. Education of Doctors and Nurses
Doctors and nurses need education led by MOH, LPPKN, the MMA, the O and G Society independently and also in collaboration with RRAAM, MNCCRCH, and • The legality of abortion and ICPD reproductive rights agreements; • The range of abortion methods including manual vacuum aspiration and medical abortion; • Managing professional ethics with personal views; • How to be more empathetic and non-judgemental about pregnant rape/incest survivors and all women with unwanted pregnancies. Doctors' Training in Gender and Rights
The MOH needs to accelerate the very good initiative begun in 1996 to train doctors in gender and rights as per the WHO RH module. Media Campaign and Policy Makers and Public Perception
A strong sustained information and education campaign of service providers needs to be planned by NGOs, MOH and the MOWFD to correctly inform the public, the media, and policy makers on the legality of abortion and to create more empathy and understanding for women in need of and eligible for a legal CONCLUSION AND RECOMMENDATION
General Policy and Advocacy Implications
Reproductive rights and national action plans
Overall, the very little progress in the ICPD area of reproductive rights extending from policies, programmes, and curricula for medical students and secondary students, reveals that there was a critical need for an implementation plan post ICPD for the area of RH and reproductive rights spelling out specifically what needed to be done, by whom, and how, in this complex area of human rights. Government, NGOs and academics need to work closely together on a definite plan of action. For this to happen, the government, especially the MOWFD and LPPKN, need to believe that the implementation of the reproductive rights approach is what women want, need and have a right to and that this will significantly improve women's health, empowerment and gender equality. NGO-GO partnership and NGO advocacy
The MOWFD, and LPPKN need to believe that diverse NGOs like the MNCCRH, women's NGOs, RRAAM and MAC in addition to FRHAM, are genuine ICPD stakeholders who need to be involved in policy and programme planning, monitoring and evaluation decisions as stakeholders not only as advisors, and that this participation will result in better policies and programmes which will benefit more people. It is often assumed that FRHAM represents all NGOs but this is not the case. Each NGO is autonomous and has its own position and experience to share. NGOs also come together as networks, committees or alliances on common objectives such as MNCCRH, NCWO, JAG, and RRAAM. For NGO advocacy, the fact that RH and reproductive rights were not on the advocacy agenda of women's NGOs until 2007, has been a big barrier, even though the first National Action Plan on Women in 1996 included reproductive rights in the women's health objective. The concept of reproductive rights thus needs to be revisited both for the principles and the concrete operationalisation into population, RH, family planning, and youth policies and programmes. What Needs to be Done, by Whom, and When?
Include more NGOs in the National Population Board
The National Population Board which has 10 places for NGOs, the public and civil society, needs to consider including more NGO representatives including women's NGO representatives rather than individuals, as NGOs can effectively represent civil society concerns on SRHR issues. Adopt the ICPD framework of reproductive rights
The ICPD framework of reproductive rights needs to be explained and promoted by NGOs for adoption by the government as the basic paradigm of family planning and SRHR programmes in the ICPD era. Economic development and human rights
NGOS, in particular FRHAM and MNCCRH, need to make an evidence-based case to government on the health and socio-economic needs and rights of poor, vulnerable, disadvantaged, and marginalised individuals (including youth) and families to prevent unwanted pregnancies through accessing high-quality contraceptive information and services. This right has to be a higher priority than the development needs of the country for expanding the population of consumers and the work force. Reproductive rights violations
Any reproductive rights violation of the government's responsibility to ensure access to contraceptive information and services and legal abortion services needs to be reported by NGOs to the Malaysian Human Rights Commission and included in the 2009 NGO alternative CEDAW Report. Strengthen MNCCRH membership and advocacy
The MNCCRH needs to be strengthened in its advocacy capacity including: • Increasing the membership of women and youth groups which are active in sex education for youth and SRHR as well as including committed SRHR policy oriented researchers; • Developing a strategic advocacy plan on SRHR. REFERENCES
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Behavioral and Brain Functions ResearchEfficacy of atomoxetine in adult attention-Deficit/Hyperactivity Disorder: a drug-placebo response curve analysisStephen V Faraone*1, Joseph Biederman2, Thomas Spencer2, David Michelson3, Lenard Adler4, Fred Reimherr5 and Stephen J Glatt6 Address: 1Department of Psychiatry, SUNY Upstate Medical University, Syracuse, NY 13210, USA, 2Department of Psychiatry, Harvard Medical School, Massachusetts General Hospital, Boston, MA 01880, USA, 3Lilly Research Laboratories, Indianapolis, IN 46285, USA, 4New York University School of Medicine, New York, NY 10016, USA, 5Mood Disorders Clinic, Department of Psychiatry, University of Utah Health Sciences Center, Salt Lake City, UT 84132, USA and 6Institute of Behavioral Genomics, Department of Psychiatry, University of California, San Diego, La Jolla, CA 92093-0603, USA

Gene Transfer from Bacteria and Archaea Facilitated Evolution of anExtremophilic Eukaryote This copy is for your personal, non-commercial use only. , you can order high-quality copies for your If you wish to distribute this article to otherscolleagues, clients, or customers by can be obtained by Permission to republish or repurpose articles or portions of articlesfollowing the guidelines