July 23, 2014 — Tamil Kendall, a Canadian Institutes of Health Research postdoctoral researcher with the Women and Health Initiative and a Takemi Fellow in HSPH’s Department of Global Health and Population, is an expert in gender and HIV in Latin America who worked in the region for over a decade. She is lead author of a new four-country study that found that health care providers in Latin America are pressuring women living with HIV to be sterilized, and are sometimes even sterilizing them without consent.
How do health care providers in Latin America pressure women to be sterilized, and why do some women capitulate to this pressure?
Health care providers are expressing the view that living with HIV means that you don’t have reproductive rights, that you can’t choose the number and spacing of your children, that you can’t choose the contraceptive method that you would like to use. Given power differentials based on gender, knowledge, and social position, when a health care provider tells you that you can’t have another pregnancy [if you’re HIV positive] and that if you try to do it you or your baby will die, so the best option for you is to be sterilized—especially if in that moment you’re in labor, or about to go into the operating theater for your cesarean section—it’s really difficult to resist. Sometimes health care providers told women that they wouldn’t be provided with health care or economic support if they didn’t agree to be sterilized. Other times women were sterilized without even knowing, while under anesthesia.
How extensive is the problem?
Roughly a quarter of the 285 women in our study—all of whom were living with HIV—reported they were pressured by health care providers to undergo sterilization. The strongest predictor of experiencing such pressure was having a pregnancy with a known HIV diagnosis. Women who had a pregnancy in which health care providers knew they were living with HIV—who were either diagnosed with HIV during prenatal care or had a pregnancy after the diagnosis—were almost 800% more likely to experience pressure to sterilize. We also found that women with two or more children were more likely to experience pressure to sterilize. So were young women, even young women without children—and normally you wouldn’t see even a small proportion of women who don’t yet have children experiencing this sort of pressure. In addition, we found that only slightly more than half of the women who participated in the study were told that there exists an intervention—a regimen of AIDS-fighting antiretroviral drugs—that can reduce the probability of HIV mother-to-child transmission by 98%–99%.
Given that this research is across four countries (El Salvador, Honduras, Mexico, and Nicaragua) and 37 different political districts in those countries—and that we see a quarter of the women reporting that they’ve been pressured by health care providers to undergo sterilization—you begin to see a common pattern of discrimination. In fact, we’ve known that coerced or forced sterilization occurs in Africa, in Asia, in Latin America. It’s not confined to one country and not even to low- and middle-income countries. Even though our knowledge is growing about how safe conception and pregnancy can be with current HIV treatments; about the possibility of dramatically reducing transmission of HIV to a partner; and about interventions to help people with HIV conceive safely, this knowledge is still often ignored as a routine part of HIV care—even in the U.S. Reproduction among people with HIV continues to be very stigmatized.
What are your future plans to combat this problem—and are you hopeful that the situation will improve?
Doing research with health care providers focused on improving their attitudes and improving the sexual and reproductive health care that women receive across the board is a priority for me. There’s also a great need to evaluate how health care providers are held accountable—in the courts, for example—for violating the reproductive rights of women with HIV. And it’s important to work with policy makers, because they are the ones who ultimately need to hold institutions accountable.
It’s heartbreaking to see cases of forced sterilizations among women that have occurred in the past two or three years. This is a serious reproductive rights violation that simply cannot be allowed to persist 30 years into the AIDS epidemic. On the other hand, there are some reasons for optimism. I think there is growing recognition and some action on the need to integrate HIV and sexual and reproductive health services, both internationally and at the country level. And there is some promising research, particularly out of Sub-Saharan Africa, indicating that health care providers are becoming increasingly aware of the possibility of preventing mother-to-child HIV transmission as well as sexual transmission with antiretroviral therapy—and that this knowledge is starting to transform attitudes.