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Rights And Realities - Vietnamese Women Speak

Maxine Whittaker

Senior Lecturer, Australian Centre for International and Tropical Health and Nutrition. 4th Floor Public Health Building, Medical School, Herston Rd., Herston Qld 4006. Phone : 61 - 7 - 3365 5415 Fax : 61 - 7 - 3365 5599 E-mail : M.Whittaker@mailbox.uq.edu.au

Introduction

The 1948 Universal Declaration of Human Rights set the stage for continued dialogue and review of human rights. Women's groups and feminist academics and lawyers have focussed on making women's experiences of human rights and their violations visible (Cook, 1993, Correa, 1997, Dixon-Mueller, 1993a, Friedman, 1995, Peters and Wolper, 1995). This decade, in preparation for the Cairo and Beijing conferences, reproductive and sexual rights have been more clearly detailed (Dixon-Mueller, 1993a, Martin, 1987, Freedman and Isaacs, 1993, IWHC and CEPIA, 1994, Germain and Kyte, 1995, Boland et al., 1994, United Nations, 1995b, United Nations, 1995a, Women's Voices '94, 1993).

As detailed in other chapters in this book, the International Conference on Population and Development (ICPD) Programme of Action clearly defined the right to reproductive health (United Nations, 1995b). This was reaffirmed at the Fourth World Conference on Women (United Nations, 1995a). Many of the discussions in preparation for and since these conferences identified the need to advocate for reproductive health and rights and to integrate this consensus of international opinion into treaties and law (Peters and Wolper, 1995, Antrobus et al., 1994). However, the need to analyse baseline realities and the size of the task to make these rights into realities has been poorly addressed (Hardee and Yount, 1995, Hempel, 1996, Jain, 1995).

Reproductive rights are not independent of other human rights - indeed they are inherently part of those rights. Part of the challenge to ensuring reproductive rights may be to work for a change in the approach to individual human rights in that government /country setting. In addition, political, social, economic and structural 'enabling' conditions are required to enable women and men to exercise their reproductive rights (Correa, 1994, Dixon-Mueller, 1993b, Petchesky and Weiner, 1990).

"Reproductive health care services are essential for the exercise of these (reproductive) rights"(Germain and Ordway, 1989 :15). UNFPA and others have recognised the need for specific health sector reform and for the expansion of health services to meet the reproductive and sexual health needs of clients and communities (UNFPA, 1997). Additionally women's rights to dignity and autonomy are being abused in the existing delivery of reproductive health services in many countries (Cook, 1995).

The International Planned Parenthood Federation (IPPF) has further detailed these sexual and reproductive rights, based on an analysis of various UN Charters and other key documents. They have elaborated twelve sexual and reproductive health rights. Under each of these Charter of Rights they have outlined a range of standards and interpretations (International Planned Parenthood Federation, 1996).

Views from the field

This chapter analyses the present status of three of these reproductive rights: the right to equality; to privacy; and to health care and health protection. I use Vietnam as a case study for other development settings in order to illustrate the present realities of rights, especially from women's points of view. The situation described for Vietnam is neither unique nor static. Many women and men in the country, and in donor communities and groups are continually working to improve the situation. This case study illustrates women's perspectives: what they see as the challenges facing them in accessing quality affordable reproductive care and transforming their rights into realities.

This chapter focuses on the health care facility as the locus of analysis rather than the national political or policy level. Lori Heise has noted "unless a woman's right to control her own body has meaning within the personal sphere of relationships, reproductive freedom will remain a distant goal" (Heise, 1995 :279). This chapter serves to complement the policy, legal and advocacy discussions in other parts of the book, by providing an analysis of rural Vietnamese women's personal sphere of health services relationships.

The data used is based on my work in Vietnam since 1993. In particular I draw upon ethnographic field work I undertook in 1997 in a Red River delta province, and qualitative work undertaken with colleagues from the Centre for Social Sciences in Health (CSSH) in the same province. I also draw upon experiences gained in developing and implementing training in reproductive health in the Vietnam Women's Union (VWU) and the Ministry of Health (MOH) between 1995 - 1997.

Why reproductive tract infections?

The UNFPA has detailed some of the consequences of denying sexual and reproductive rights worldwide. Amongst these are morbidities and mortalities related to reproductive tract infections (RTIs). For example: "1 million people die each year from reproductive tract infections, including sexually transmitted diseases (STDs) other then HIV/AIDS. There are an estimated 333 million new cases of STDs per year" and "Six out of ten women in many countries have a sexually transmitted disease. All face a higher risks of infertility, cervical cancer or other serious health problems" (UNFPA, 1997 :3).

Reproductive tract infections (RTIs) are one area of the largely neglected field of reproductive health that has been increasingly gaining attention by family planning services and reproductive health managers and advocates (Grant and Measham, 1996, Jacobsen, 1991, The World Bank, 1994, Wasserheit, 1989, Whittaker and Larson, 1996).

RTIs are defined as including "a variety of bacterial, viral and protozoal infections of the upper and lower reproductive tract of both sexes, and most of them are STDs" (Dixon-Mueller and Wasserheit, 1991 :2). They are three "routes" of transmission, namely:

• STDs such as chlamydial infection, gonorrhoea and trichomoniasis;

• endogenous infections which are caused by an overgrowth of organisms that may be present in the genital tract of normally healthy woman such as bacterial vaginosis and vulvovaginal candidiasis, and;

• iatrogenic infections which are associated with medical procedures such as

obstetric and gynaecological procedures and IUD insertions (Germain, 1991).

Setting the scene

Reproductive health services in Vietnam are provided in both formal and informal settings, in the public and private sector. In the formal public sector setting, the focus of this paper, the Ministry of Health (MOH) provides primary health care services through the commune health stations (CHS). Located in each commune throughout the country, these facilities are reported to be in varying states of repair and function (Marr, 1995, Truong Viet Dung et al., 1995). In theory every CHS is staff by one assistant doctor, two nurses, one midwife and one doctor, however these staffing levels are not often reached.

The CHS undertakes prevention of various communicable disease such as immunisable diseases of childhood, monitors the hygiene conditions in the commune and provides simple management of some health problems such as respiratory and diarrhoeal infections, analgesic pain relief and simple trauma. The majority of treatment provided is based upon history taking and simple physical examination. Laboratory facilities are rarely available at this level. The CHS usually consists of a few rooms located near the commune official buildings. It may have 1 - 5 beds for overnight patient stays.

The CHS staff often manage a small pharmacy which sells a range of essential drugs and other herbal and proprietary medicines. Referral of more complex problems is made to the district and provincial level hospitals or maternal and child health/family planning centres, or specialist centres eg. the Institute of Venereology. The CHS and district hospitals are usually accessed by walking, riding a bicycle or motorcycle or getting/paying for a lift from someone.

The reproductive health service at the CHS is usually limited to the provision of information on family planning, gynaecological examinations and management of uncomplicated pregnancies and deliveries. Oral contraceptive pill and condom supplies are now mainly available through the social marketing programme of the National Committee for Population and Family Planning (NCPFP).

For the majority of women, IUD insertions and removals, abortions and gynaecological examinations are performed by the district or provincial health services and their mobile teams during scheduled weekly visits. Often these teams only consist of one trained midwife who travels by motorcycle to the CHS. Annually a two to three day, family planning and gynaecological campaign is conducted. Women are informed by mobilising local motivators, health staff and women's union members and using loudspeakers. The services are provided by district/provincial teams of doctors, midwives and/or assistant doctors.

The ethnographic data used in my analysis was collected in a typical district of a Red River delta province in northern Vietnam. The centre of the district is located approximately 15 kilometres from the provincial town. The district hospital is located a few kilometres away from the centre. Wet rice farming is the principal productive activity for the households of the district. Some families have their income supplemented by hiring their labour to other landowners, migrating to the Central or Southern provinces to work on plantations, mines and construction and/or growing secondary crops such as sweet potato, corn and cassava

or animal husbandry. Some of the 15 communes of this district suffer crop losses every year due to typhoons and flooding. The total population of the district was estimated in 1994 to be 114,800 of whom 27,100 were women aged between 15 - 49 years of age (NCPFP and GTZ, 1995). The district is considered one of the poorer within the province, and the province is economically average or below for the Red River delta.

The right to equality

"3.1 No person should be discriminated against in their sexual and reproductive lives in their access to health area and/or services" on the grounds of race, sex, language, political opinions, social origins or property.

"3.5 No person should be subjected to any sexual or reproductive health care programme which has the effect of discriminating against a particular population group" (International Planned Parenthood Federation, 1996).

This "right" is violated on a daily basis in the delivery of health care in many countries. A discussion of reproductive health encounters in Northeast Thailand for example, found women discussing how health staff were "speaking rudely" to them, providing information poorly and having a brusque manner and tone of voice. The author (Whittaker, 1996) linked these behaviours to inequalities of power, fundamental to gender, class and ethnicity. Other authors have described similar behaviour such as in Nepal (Schuler et al., 1985), West Africa (The Prevention of Maternal Mortality Network, 1992), Nigeria (Okafor and Rizzuto, 1994) and India (Gupta, 1993). Health care providers use power and gender relationships to limit women's reproductive rights (Heise, 1995).

Women in my study district clearly felt that they were discriminated against in terms of access because of their poor economic and living conditions. Repeatedly women described the behaviour of various levels of health and family planning staff towards them.

When the rich and the poor have disease they go to hospital. In the situation where the poor arrive at the same time as people who have money - the health worker will speak 10 sentences with the rich. They will only speak with the poor for 1 or 2 sentences. They let us sit, like, we joke, a "flu dog" (a dog sick and miserable with the flu), sitting in the corner" (Ba Phung, FGD 12).

Discussions with health staff and government authorities demonstrate that these discriminatory attitudes and behaviours are widespread. Some providers' "disdain" for women with vaginal discharge is well illustrated by the comment made by one male commune assistant doctor. We were discussing some vaginal discharges such as "thrush". He broke out laughing :

This fungus is common. The women with fungus itch and scratch. They stand in the door of the commune health station and scratch, scratch, scratch. (FGD 4).

During the training of provincial, district and commune level health staff and VWU motivators we were role playing a bad reproductive health consultation. My field notes demonstrate this discriminatory attitude:

I went to one group and asked who was playing the role of client with a vaginal discharge and who the role of the health worker. Two of the team members pointed to one woman in the group - a commune motivator who was dressed in typical commune clothes. Spontaneously one of the group members explained to me that this woman was chosen to play the role of a woman with discharge as the other women in their group were pretty and dressed too well to have discharge. Others in the group said "it more women like her who have this problem". (Field notes April 1995)

Not all staff treat women in this manner and examples of good practice, caring attitudes and support were also given readily by women. Some staff were clearly embarrassed by comments like those above, and tried to "reprimand" their colleagues.

Gender relationships play a role in denying women their right to dignity and to services.

In another training activity held with provincial and district health staff, we were reviewing a role play of a bad consultation. The doctor, played by a male, finished an abrupt interview as his example of a poor provider - client interaction. When asked his thoughts about the 'consultation' he commented:

Actually with a woman this good looking I would probably spend all day with her. (Field notes April 1995)

Such discriminatory practices make women reluctant to seek care. These repeated experiences erode women's status and power - a vicious spiral of disempowerment (Dixon-Mueller, 1993a).

It is a horrible experience. Women feel scared and afraid. (Dung in-depth 16.)

They scold us saying "Why don’t you wash - why do you let it (the genital region) become so dirty and very smelly. ..,. The health workers say harsh words which make women lose their self respect. (Ngoc In-depth 24.)

Bruce discussed how client's view their rights as a desire for dignity and fair treatment. (Bruce, 1987). The women I interviewed clearly state these desires. They provide concrete examples of violations of this "right" that can be observed during interactions, and heard in conversations with officials and health professionals. They want better relationships with the health care providers and motivators which would then "support" their use of the services, and their right to access care. Other authors have noted the importance of provider-client relationships in reproductive health settings (Whittaker and Larson, 1996, Whittaker et al., 1996, Mensch, 1993, Koenig et al., 1997, Huezo and Diaz, 1993, Bruce, 1990).

The right to privacy

"4.1 All sexual and reproductive health care services including information and counselling should provide clients with privacy and ensure that personal information given will remain confidential "(International Planned Parenthood Federation, 1996).

There is always a risk of infringing and intruding on rights to privacy when dealing with RTIs, especially notifiable or contagious sexually transmitted infections (STIs). Part of the management of STIs may include contact notification and tracing (Spicker, 1987, World Health Organization, 1994). Care must be taken that individual rights are not compromised and the counselling of the client should stress her/his responsibilities in advising contacts. In addition, the provider may need to assist the client, particularly women, in negotiating with their partner/s about this issue (Meursing and Sibindi, 1995, Worth, 1989, Dixon-Mueller, 1993b). International standards for provision of reproductive health services identify the provision of auditory and visual privacy as important (Association for Voluntary Surgical Contraception International , 1995). Even in the poorest of settings, this privacy can be provided eg. through staff lowering their voices, hanging some cloth as a screen, talking to the client as they walk.

In many settings, however, privacy for any consultation may be limited. Often, when discussing this issue, I have had donors, managers and providers state that because women live in crowded conditions, they do not desire privacy. Discussions with women tell a different story.

Many women think that the reproductive organ is a secret organ. So we don't want to show others - to let them see it. We are very shy and ashamed when we have an examination … Maybe we show a normal attitude on the outside but in fact we are very shy and ashamed on the inside. (Sim, Indepth 15.)

We are reluctant to talk about these problems. We don't want to talk about them. We only want to talk to a woman doctor, because we only want to find a doctor to have medicine to treat the disease, so we have to go. It is a secret story, so we cannot tell others (An, Focus group discussion 2).

In one of the observed communes, 110 of the 195 intra-uterine devices (IUDs) inserted in 1996 were performed on 2 days in April, with 77 women receiving their IUD on one day. In 1997 in another commune, 69% of the total year's IUD insertion were performed in a campaign of 5 days duration - with more than 50 clients a day being seen on 2 days (Field notes February 1996, Field notes March 1997). The ability to provide privacy to clients is severely limited in such a setting. Many health care staff are immune to or unaware of the breech of privacy occurring. "It is funny to watch all the women as they line up and are examined". (Head of CHS, Field notes 17.2.1.)

An example of women's experiences in these clinics and campaigns is noted in field notes of a mobile clinic.

Women had to take their pants off whilst standing next to the gynaecological examination table and then jump up when it was their turn. … Three women were very shy. When they took their pants off whilst queuing by the table, they crouched down to let their shirt cover their pubic regions. … At this stage the commune women's union president comes into the room again. There were now 16 women in the examination room - including the client (on the table), the midwife, the health worker recording client details and the worker cleaning the instruments, the Head of the commune health station, the VWU president, my research assistant and me, and other 8 clients - at least 2 whom were already "stripped". …. Some women peer through the glass of the door at the head of the bed. … There is no cover sheet to cover the woman when she lies on the examination table. There are a lot of people moving in and out of the room. (Field notes 23.1.97)

Even after the consultation, women's privacy is invaded. Management and health information systems require a variety of people need to access clinic records. During these occassions, confidentiality is often breeched. For example:

After the mobile clinic, the chairman of the Commune People's Committee (male) and the President of the Commune Women's Union were in the health station staff room. They were checking the records of the clinic, noting who had visited the clinic and what service they had received". (Field note 13.3.1)

Women often over-hear consultations and tell others what they heard. These descriptions can be detailed - one informant described the colour, amount and character of another woman's discharge to me. Another informant confirmed that her former neighbour still was receiving care for a condition, because she had checked the clinic record book last time she went to the health centre and saw that her neighbour's name was still there. One women described the clinic like a "market place" where everybody talks about and can hear everybody else's business. This lack of privacy discourages women from seeking care. They desire privacy, but for them it is "normal" to have none.

The right to health care and protection

"9.1 All persons have the right to the highest possible quality in health care including all care related to their sexual and reproductive health.

9.2 All persons have the right to comprehensive health care services including access to all methods of fertility regulation including safe abortion and diagnosis and treatment for infertility and sexually transmitted diseases including HIV/AIDS

9.5 All persons have the right to sexual and reproductive health care services as part of primary health care which are comprehensive, accessible, both financially and geographically, private and confidential and which pay due regard to the dignity and comfort of that person" (International Planned Parenthood Federation, 1996).

Access to health care is one of the main foundations required to establish reproductive rights. In many developing countries, this access is still limited (Meliala, 1994). A woman's right to life entitles her to access basic reproductive health services including the management and prevention of RTIs (Cook, 1993). Access can be considered under four main variables: physical access of a facility; ability of the facility and services to meet the needs in a quality manner; affordability of the services provided; and acceptability of the services provided (Timyan et al., 1993, Thaddeus and Maine, 1990). In this section I concentrate upon technical competence of the staff to provide care, and physical access to services.

Quality health care requires as one of its foundations, knowledgeable and skilful providers of services and an effective and utilised referral system (Mensch, 1993). A range of assessments in Vietnam have highlighted the low knowledge and skills levels of providers from the commune to the national level on family planning and reproductive health (Alam et al., 1995, ICOMP, 1996, Knodel et al., 1995, Phan Thuc Anh et al., 1995, Truong Viet Dung et al., 1995, Jain et al., 1993).

In the work with the MOH/NCPFP/VWU, all provincial to commune level trainees were pre-tested. The results showed inadequate knowledge of family planning methods; incorrect attribution of RTIs and discharges as a contraindication for use of some family planning methods; and that not one of the 40 respondents could describe correctly how to sterilise equipment eg. speculums. Poorly cleaned instruments can be one portal of infection with RTIs - an iatrogenic cause (Germain, 1991).

Similarly, in a VWU training workshop, the majority of women's union motivators, nurses, midwives and providers did not understand the role of or normality of physiological discharge. Provincial, district and commune level providers misunderstood the range of RTIs, their signs and symptoms and their appropriate treatment. In addition, most providers were unaware of the need to, and did not provide counselling on prevention of sexual transmission of many of these infections. Even if mentioned, condoms were rarely available from the health centres and there was limited availability from the private sector in the observed rural communes. Such poor levels of knowledge, skills and understanding have also been noted in a study undertaken in Hue, Vietnam (Nguyen Thi Loi, 1997).

The duration of consultations often precludes provision of quality care. In a sample of 15 observations in 1996, only 2.6 minutes on average were spent on history taking of new and old clients and 2 minutes for clinical examination. In the mobile clinics this time was even shorter. During one "campaign" more than 70 women were examined in a 7 hour working day.

As mentioned earlier, iatrogenic spread of RTIs is a major concern. Sterile technique, proper cleaning and sterilisation of instruments, and cleanliness of the facility and staff, are the major means to prevent this route of transmission. However, funding difficulties (resulting in too few supplies), poor logistical systems (resulting in stock-outs and unreliability of supply) and limited provider knowledge mean that most services provide sub-optimal infection control. For example, during the 15 observations across 5 service delivery sites, the same pair of gloves were observed to be used for all clients observed - the provider only occasionally washing of the gloves between clients. Three fifths of the IUD insertions observed were not performed using the prescribed sterile technique. Usually it was observed that there is a clean sheet under the buttocks of the first client for the day. It is then not changed until the end of the clinic session after ten or more clients have laid upon it.

Women themselves recognise and are concerned about the possibility of iatrogenic infection.

Maybe the medical instruments causes (reproductive tract) infections. ... Maybe they are not cleaned nor sterilised properly. This may be the reason why so many women have an infection after IUD fitting. (Sim, Indepth 12).

The Head of the Provincial MCH-FP Centre confirmed the widespread nature of poor clinic infection control. She identified the lack of provider knowledge, poor staff attitudes and lack of adequate numbers of instruments and autoclaves as causes of this problem. During discussions with the VWU, they were also concerned. For example, during the campaigns often 50 - 70 women are seen in a day, but each team may only have 5 speculum to use for these clients. They requested more speculum to be provided to enable them to provide sterile conditions.

The clinical diagnosis and management of RTIs can be inadequate and incorrect. Often only 1 -2 days of treatment are given eg 4 tablets of 250 mg of ampicillin; one suppository tablet of mycostatin rather than a three, five or seven day course of treatment. Metronidazole was a popular vaginal medication prescribed even though it was only sometimes the appropriate treatment. This poor management of RTIs has been noted by others in Vietnam (Nguyen Thi Loi, 1997) and internationally (Wasserheit, 1989, Whittaker and Larson, 1996, Germain, 1991, Grant and Measham, 1996).

The unreliability of existing services is a concern for women and for programme managers. Commune health stations are often not open or not appropriately staffed. Hospital staff may be in meetings or away on training, and mobile clinics although scheduled weekly, may not be so regular. For example, in one commune, during 10 weeks of field work, the mobile team came only twice, not the scheduled 10 times. From this commune's clinical records in 1996, there were only 13 clinic days and no clinics were held in February, June, July, October or November. In another commune only 16 clinics were held that year.

Because the women cannot rely on the mobile clinic occurring every week, they wait to be informed. However often the health staff and the Women's Union motivators do not get much advanced notice either. As one women noted:

Suddenly the district and the commune staff and motivators come to inform us that the mobile clinic is operating - but we have gone to work. (Thanh, FGD 13).

A woman's ability to access services may be limited by her "status" in the family. Many women described the need to have their husband's permission to seek care, especially if money is needed for treatment and/or if the woman needs time off from household and agricultural activities.

If your husband doesn't agree - you don’t go for treatment. Only when your husband agrees. Otherwise he will scold and intimidate you. If your husband doesn't let you go and you try to go, he will say, "If when you return you are weak or have some trouble, I will not pay you any attention, I will not care for you or your condition". (Dung, Indepth 16).

Implications

The case study of Vietnam illustrates many of the realities women face. Programme managers in many developing countries face similar difficulties in trying to service the reproductive rights of women. These include: inadequately trained staff; poorly motivated staff with discriminatory attitudes; inadequate supplies; inadequate information and education activities; organisational barriers to the provision of privacy and confidentiality; and disempowered clients who cannot place their demands for better quality and for their "rights" (Germain and Kyte, 1995, Dixon-Mueller, 1993a, Antrobus et al., 1994, Whittaker and Larson, 1996).

Systematic approaches are required to address these problems. Time and resources are necessary to implement these programmes. Sustained support at national and international level for improvements is required. “The barriers to achieving major improvements in quality of care should not be underestimated, especially in resource poor bureaucracies . . . Significant and sustained improvements will necessitate fundamental changes in programme philosophy and orientation” (Koenig et al., 1997 :286).

The effort to make reproductive rights a reality requires resources (Hempel, 1996). UNFPA estimated the monetary costs of a family planning and reproductive health programme for the world's developing countries. This estimate was based on a range of assumptions which they acknowledge may underestimate the size of the problems and the status of existing baseline services and skills. They calculated that by the Year 2000 it would cost US$17,000 million annually to provide family planning and reproductive health services in developing nations. They also assumed that two thirds of the funding for the services would come from the developing nations themselves (Hardee and Yount, 1995, United Nations, 1995b). A recent review has found a shortfalls in both the proportion and size of contributions to reproductive health funding compared to that pledged by donor and recipient countries at ICPD (Rockefeller Foundation, 1998).

Adequate funding is one part of mechanism to ensure rights can be realities. Some authors have discussed the need for policy and political support, improved resource allocation and utilisation and programme management structures that provide and support the provision of quality of care and access to reproductive health services (Bruce, 1990, Mensch, 1993). These needs have also been demonstrated in this chapter.

The need for improved basic, refresher and in-service training in technical, respect for client needs eg. privacy and communications skills has been highlighted in this analysis (Dixon-Mueller, 1993b, Zurayk et al., 1996). However, training requires reinforcement through supervision and management; needs to be part of a quality improvement system that can provide updates as required, and requires the facilities, supplies and equipment to be available to practice what is taught (Huezo and Diaz, 1993). The international efforts to develop appropriate cost-effective diagnostic and treatment guidelines are also needed (Grant and Measham, 1996, Nguyen Thi Loi, 1997, World Health Organization, 1994). The assurance of delivering value -neutral services (without gender, ethnic, class, religious discrimination) requires the reinforcement of the desired values throughout the management structures - in the health sector, and beyond (Huntington et al., 1990).

The increasing interest in RTIs is welcomed - especially the well-meaning and urgently needed search for appropriate management guidelines for example the syndromic approach (World Health Organization, 1994) and the search for microbiocides (Elias and Heise, 1993). But one needs to be cautious of potential erosions of women's rights. The concern is that medical knowledge of RTIs will displace women's knowledge of "their own bodies, their own lives and their own needs and deny the reality of women's experiences" (Dixon-Mueller, 1993a :50, Martin, 1987). We will have to ensure that women maintain the locus of decision making regarding their lives and we must monitor the level of "medical control" developing over women's bodies. Health professionals/ workers must be supported to strengthen or in some cases even develop their "educational" role to enable and support women to have and maintain this control over their own bodies (Bondeson, 1987).

Conclusions

Many have noted the large step that has been taken in recent years with the recognition of reproductive rights as part of human rights (Correa, 1997, Germain and Kyte, 1995). However this legal framework is only a tool (Germain and Kyte, 1995). The transformation of rights into realities for many women and men remains a big step requiring political will, national and international financing, monitoring and evaluation and equal participation for citizens. It needs concerted efforts by all - nationally and internationally to advocate for reproductive rights, funding of reproductive health care services and maintaining/increasing allocations of developed countries to development assistance especially in the interlinked social sectors of health, education, poverty alleviation and human rights.

Women want their rights to be recognised, and we need to be part of the effort to ensure that their voices are heard and their needs and desires are met.

We only hope that the government gives priority to women, provides medicine to treat women's diseases and protects us against these diseases. Rural women have no little information or documents about these things. … So help rural women have the information and education to study about and protect themselves against these diseases. (Ghi FGD 2 lines 1388 - 1402).

Acknowledgments

Many people and organisations have assisted me and contributed towards this article and the field work and analysis that supports it. The women, men, managers and health staff in the province, district and communes need special mention and thanks. They continue to provide me with insights and stimulus to continue in this work. The Ministry of Health, National Committee for Population and Family Planning, and the Vietnam Women's Union have been especially supportive of my work in Vietnam and I look forward to continued working relationships. The research staff of the Centre for Social Sciences and Health with whom I have worked and collected some of the data discussed in this article are acknowledged for their collegial and professional assistance. The data collected was from research funded by the World Health Organisation and the Australian Centre for International and Tropical Health and Nutrition. Finally I wish to extend my appreciation for their editorial and review support to Professor Lenore Manderson and my husband, Neville Smith.

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Senior Lecturer, Australian Centre for International and Tropical Health and Nutrition. Address correspondence to : Dr M.Whittaker, ACITHN, 4th Floor Public Health Building, Medical School, Herston Rd., Herston Qld 4006. Phone : 61 - 7 - 3365 5415 Fax : 61 - 7 - 3365 5599 E-mail : M.Whittaker@mailbox.uq.edu.au

Chapter 2 Principle 8 of the ICPD Platform of Action states "Everyone has the right to the enjoyment of the highest attainable standard of physical and mental health. States should take all appropriate measures to ensure, on a basis of equality of men and women, universal access to health care services, including those related to reproductive health care, which includes family planning and sexual health. Reproductive health care programmes should provide the widest range of services without any form of coercion. All couples and individuals have the basic right to decide freely and responsibly the number and spacing of their children and have the information, education and means to do so", UN 1995a.

The Beijing Declaration and Platform of Action stated "Increasing women's access throughout the life cycle to appropriate, affordable and quality health care and related services, … undertake gender sensitive initiatives that address STD, HIV/AIDS and sexual and reproductive health issues; increase resources and monitor follow-up for women's health". UN 1995b

The Glen Cove meeting of Treaty Organisations as held in December 1996. It consisted of all the bodies of the United Nations system responsible for monitoring human rights treaties (6), 10 UN organisations and a number of NGOs. The meeting was called by the UNFPA, DAW and UNHCR. For a summary statement see UNFPA 1997 page 27-8

This Chapter will not explore human rights in any more detail. It is beyond the scope of the paper.

Statement from the International Call for action from the 1988 Symposium entitled "Women's health in the third world : the impact of unwanted pregnancy". The conference was held in Brazil in October 1998 (Anonymous, 1989).

These documents include the Standards from: the Programme of Action of the UN ICPD Cairo 1994; Nahid Toubia 1994 article on female circumcision as a public health issue; the Platform of Action from the UN 4th World Conference on women Beijing 1995; the International Covenant of civil and political rights (ICCPR) 1966; the World Conference on Human rights 1993; the World Medical Assembly Declaration of Oslo 1970; the Programme of Action of the UN World Summit for Social Development Copenhagen 1995.

These IPPF Reproductive rights are :

1. The right to life

2. the right to liberty and security of person

3. the right to equality and to be free from all forms of discrimination

4. the right to privacy

5. the right to freedom of thought

6. the right to information and education

7. the right to choose whether or not to marry and to found and plan a family

8. the right to decide whether and when to have children

9. the right to health care and health protection

10. the right to the benefit of scientific progress

11. the right to freedom of assembly and political participation

12. the right to be free from torture and ill treatment.

The donor funded projects often increase the level of family planning services available. In these areas, trained midwives are often allowed to perform IUD insertions and removals, and abortion services.

The Introductory Study of DMPA in Vietnam : an opportunity to strengthen quality of care in family planning service delivery is being undertaken in three provinces in Vietnam - by the Ministry of Health, the National Committee for Population and Family Planning and the Vietnam Women's Union. Funding is provided by the Government of Vietnam, the World Health Organization, the UNFPA and the GTZ.

One of the alternative solutions to this problem, is removing the need for and commitment to campaign approaches.

United Nations Population Fund ( formerly called the United Nations Fund for Population Activities)

At the ICPD industrialised nations agreed to increase their share of reproductive health financing from the then current 1994 levels of US 1.6 billion to US 5.7 billion by 2000. This would take their share of financing to one third of the costs - the remaining costs being borne by the developing countries themselves. This required developing nations to increase their financing by 8.5% per year to the year 2000 to reach the target. According to Rockefeller 1998, in 1996 preliminary ledges to reproductive health donor assistance were only $US 1 billion, less than 25% of the total costs of implementing the Cairo Programme of Action. They also note that donor contributions have changed little since 1996 and actually declined for some donors. Changes in global economic status also have eroded the US dollar value of many donors contributions and have threatened the ability of Asian nations to finance at required levels.

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