Document - Burkina Faso: Briefing to the Committee on the Elimination of Discrimination against Women: 47th session, October 2010
Briefing to the UN Committee on the
Elimination of Discrimination against
Amnesty International submits the following information for consideration by the UN Committee on the Elimination of Discrimination against Women (the CEDAW) in advance of its examination of Burkina Faso’s sixth periodic report under Article 18 of the Convention on the Elimination of All Forms of Discrimination against Women (the Convention).
This briefing is based on Amnesty International’s field research in Burkina Faso and focuses solely on issues relating to maternal mortality. The information submitted is based on an Amnesty International report entitled Giving Life, Risking Death published in January 2010.1 It highlights in particular concerns in relation to the following articles:
Article 2: Condemnation of discrimination against women
Article 5: Gender role stereotyping and prejudice
Article 12: Right to access health services
Article 16: Marriage and family life
1. Discriminative status of women and stereotyping of gender roles (Articles 2, 5 and 16)
Women in Burkina Faso suffer discrimination in many areas of their lives, with unequal access to education, health care and employment. Particularly in rural areas, women have little or no say in key domestic decisions. They are primarily valued as wives and mothers, and if they do not have children they risk abandonment and rejection, sometimes even domestic violence. Such discrimination makes it difficult for women to choose the timing and spacing of their pregnancies. The fertility rate is high, at 6.2 children per woman, and even higher in rural areas at 6.9, according to the national Demographic and Health Survey of 2003.
Women’s lack of power, linked to economic dependence and subordinate status,means that women who need their husband’s permission and funds to obtain health care have to adopt bargaining strategies. These bargaining strategies include offering to make a contribution (if the wife has savings), turning to mediation through in-laws, and confrontation, where the woman reminds her husband of his responsibilities towards her or threatens to return to her parents.2
Early marriages are common and the law allows girls to be married at a younger age than boys (17 for girls and 20 for boys, which may be reduced to 15 for girls and 18 for boys). This provision only applies to civil marriages. In rural areas, many people marry according to traditional rules with no minimum age, and girls as young as 10 are often married. An official study recently found that the majority of teenagers were married off between the ages of 14 and 19.3In addition, young women in rural areas are more likely to bear children, with 157 per thousand rural adolescents becoming mothers, compared with 64 per thousand in urban areas.4
Female genital mutilation is also widely practiced (according to the Demographic and Health Survey of 2003, 77 per cent of the women report having undergone this practice), even though it has been banned by law. Both practices discriminate against women and create risks for pregnant women’s health.
2. Poor Access to sexual and reproductive rights information and services (Article 12)
More than 5,000 women died in Burkina Faso between 1995 and 2000 as a result of pregnancies that were unintended, according to a statistical analysis published in 2002.5 Contraceptive use is low and family planning services are severely under-funded.
The government of Burkina Faso continues to inadequately address issue of access to safe and confidential access to sexual and reproductive health information and services. The result is a large number of early, unwanted or life-threatening pregnancies, as well as unsafe abortions.
Abortion is only allowed in restricted cases (in case of rape, incest or if the life of the pregnant women or the unborn child is in danger), and is otherwise classified as a crime by the Penal Code. However, even when abortion is permitted, the conditions set by the law are complex and difficult to meet, and most of the women met by Amnesty International in rural areas were not aware of these provisions.
Some women cannot afford contraceptives – although consultations are free, contraceptive products have to be paid for. Some women cannot obtain them because supplies are not available. Others are prevented from using family planning by their husbands and/or are deterred by lack of information, often giving rise to misplaced fears.
Women told Amnesty International that many public family planning services were run by men who tried to deter them from using contraceptives. They also complained about a lack of confidentiality.
3. Barriers to access to adequate healthcare (Article 12)
Pregnant women have to overcome several barriers to access medical care, notably social, geographical and financial obstacles. Health care facilities are often far from people’s homes, especially in rural areas, and transport is unreliable and expensive. Although the government has increased the number of community health centres in recent years, enormous disparities continue to exist between urban and rural areas, notably in the Sahel region where the maternal mortality rate is the highest of the country.
Despite government subsidies as provided for by legislation in the 2006 subsidy policy, the cost of health care still prevents women from receiving life-saving treatment, and families nearly always have to pay more in practice than they should.
The 2006 subsidy policy specifies that the cost of deliveries will be subsidized by 80 per cent, that transport between a health centre and a referral hospital will be free and that indigent pregnant women receive free health care. The main problems undermining the implementation of the subsidy policy are:
confusion among the public and medical staff over what is subsidized and what is free, allowing health care staff to demand unofficial payments for treatment, supplies or transport;
absence of free transport between health facilities;
failure to identify indigent women entitled to free care – no criteria for identifying them have been made known.
In practice, the subsidy policy is also undermined by the fact that health care staff often demands unofficial payments for treatment, supplies or transport.
4. Inadequate quality of maternal healthcare (Article 12)
The health care system suffers from several recurrent problems: inadequate health infrastructure; shortages and interruptions of supplies of drugs and medical equipment; blood shortages; lack of trained medical personnel and lack of skilled birth attendants.
Some health centres visited by Amnesty International were very run down, with broken windows and holes in their sheet metal roofs. Health facilities are desperately short of space and Amnesty International saw women in a university hospital who were about to give birth or had just given birth sleeping on the floor in the corridors. In many of the health facilities visited, some essential supplies were damaged or missing. In addition, many medical staff complained of interruptions to supplies and delays in restocking drugs and equipment.
The referral system is the basis of any functioning health system, allowing complications to be treated at a higher level of care. In Burkina Faso, community health centres can only carry out normal deliveries and have to refer to a higher tier (district, regional and university hospitals) any pregnant women suffering complications. This referral network is undermined by several deficiencies, including delays in making the decision to refer a patient and lack of emergency capacity in district and regional hospitals.
Moreover, although there has been an increase in medical personnel in the last five years, there are still inadequate numbers of qualified medical staff in Burkina Faso. Medical staff stressed that low public sector salaries were detrimental to the quality of treatment. Many women and their families complained also of inappropriate and sometimes violent behaviour from medical staff during deliveries.
5. Need for real accountability (Article 12)
Amnesty International has raised with the authorities of Burkina Faso its concerns about the lack of accountability of members of the medical personnel, as well as an insufficient implementation of government’s policies. During a mission to Burkina Faso in February 2010, an Amnesty International delegation met with the highest authorities, including the President of the Republic, Blaise Compaoré, the Prime Minister, Tertius Zongo, the Minister of Health, Seydou Bouda, and the President of the National Assembly, Roch Marc Christian Kaboré. The authorities acknowledged the issues raised and committed themselves to lift financial barriers that prevent women from accessing the health care they need when they give birth. However no concrete steps have been taken yet to honour this commitment.
In its report, Amnesty International stressed that patients are also entitled to claim their right to health and to hold accountable medical personnel who might be responsible for abuses or misconduct, such as unlawful demands for unofficial payments, and must have access to avenues of redress.
However, in Burkina Faso, accountability is rare. Corruption by medical personnel, notably unofficial payments, is a major element undermining the whole health care system and in particular the subsidy policy. It is therefore very worrying that the government of Burkina Faso seems to be doing little to tackle it.
6. Summary of recommendations Amnesty International has made to the authorities of Burkina Faso aimed at addressing maternal mortality, notably with regard to discrimination against women
With a view to ensuring enhanced respect for the women’s right to health, and notably to be free from discrimination, Amnesty International has called on the Burkina Faso authorities to:
Uphold its obligation to take all appropriate measures to end discrimination against women in all its forms, including the elimination of customary practices which are harmful to women. The government should review its national legislation to ensure that early marriages are forbidden and that any discrimination between men and women regarding the age of marriage is removed; and ensure that harmful customary practices such as FGM – prohibited by law – and early and forced marriages are eliminated.
Ensure that all women know their reproductive health rights. It must undertake information and education campaigns aimed at both women and men to provide accurate, evidence-based, and comprehensive information about contraceptives. The authorities should also take steps to ensure confidential access to such services and information for all women, including adolescents. Finally, they should take all necessary measures to ensure that safe and legal abortion services are available, accessible, acceptable and of good quality for all women who require them in the circumstances as set out in national legislation, and repeal the provision of the Penal Code permitting the imprisonment of anyone who carries out an abortion.
Implement immediately and in full the subsidy policy in all health facilities and create robust monitoring and accountability systems, and as a matter of priority the policy for women who are entitled to a total exemption from costs related to health care by identifying and publicizing the criteria to qualify for total exemption. The authorities should consider introducing a total exemption from fees charged for services, drugs and supplies for reproductive health services, including emergency obstetric care.
Ensure the progressive and equitable distribution of health facilities, goods and services throughout the country; increase the recruitment of qualified staff, create incentives to encourage qualified staff to work in rural areas, and ensure that they receive adequate training and support.
Ensure that monitoring, evaluation and accountability mechanisms should be strengthened, including through systems to combat corruption and mismanagement in procurement, storage and distribution of drugs and supplies. Any complaint mechanisms should be readily accessible to people and well publicized.
1 Amnesty International, Giving Life, Risking Death (Index AFR 60/001/2009), available at http://www.amnesty.org/en/library/info/AFR60/001/2009/en.
2 See the study by Béatrice Nikièma, Slim Haddad, Louise Potvin, “Women bargaining to seek health care: norms, domestic practices, and implications in rural Burkina Faso”, World Development, April 2008, Volume 36(4), p. 615.
4 Demographic and Health Survey of 2003.
5 Nils Daulaire et al., Promises to Keep: The Toll of Unintended Pregnancies on Women’s Lives in the Developing World, Global Health Council, 2002, p. 42