RCOG response to the International Development Committee inquiry into ‘FCDO’s approach to sexual and reproductive health’

Background

The Royal College of Obstetricians and Gynaecologists (RCOG) works to improve women’s healthcare across the world. The Centre for Women’s Global Health delivers the RCOG’s mission to improve girls’ and women’s sexual, reproductive and maternal health in low and middle-income countries. We work with local partners to promote access to available, acceptable, high quality sexual and reproductive health (SRH), gynaecological and maternal health services to ensure women and girls can realise their right to health. This is critical to achieving the UN’s Sustainable Development Goals 3 (SDG3) on maternal mortality and 5 (SDG5) on gender equality and empowering all girls and women by 2030.

In recent years, the Centre has successfully implemented global health projects to: address maternal mortality by strengthening the skills of healthcare workers in emergency obstetric skills in Myanmar, Somaliland and Uganda; raise awareness of the burden of gynaecological disease and build the skills of non-specialised doctors and nurses to deliver quality, respectful gynaecological care in Bangladesh; and expand contraceptive choice and advocate for improved access to safe abortion and post abortion care in Nigeria, Sudan, Zimbabwe, Rwanda, Sierra Leone, Tanzania and South Africa.

Our operational model places members, and the women they serve, front and centre of all we do. We provide clinical expertise that helps to improve health service delivery, often through the training of non-specialist health providers. Additionally, we use our clinical expertise to advocate for the importance of prioritisation of sexual and reproductive health rights.

1. Is the FCDO's approach to sexual and reproductive health programming in lower-income countries sufficiently responsive to the needs of communities in lower-income countries, including in its new Sexual and Reproductive Health and Rights programme?

The FCDO occupies a unique position within the SRHR donor landscape, as both one of the largest donors in support of SRHR services and supplies and as one of the most comprehensive in its approach to SRHR programming. As a former architect of the FP2020 Initiative, the FCDO has historically been a global leader in support for the provision and delivery of contraception counselling, services and supplies. It has also supported broader SRHR interventions such as comprehensive sexuality education, maternal and neo-natal health and gender-based violence.

However, the FCDO’s programming does not currently address the global burden of gynaecological disease, as a priority in its own right nor as a key element of its integrated SRHR response. This is a glaring omission: globally, gynaecological health is one of the least prioritised areas of health, despite the enormous burden of morbidity and mortality. Cervical cancer is the fourth most common cancer among women globally, with around 90% of new cases and deaths worldwide in 2020 occurring in LMICs [1]. Other so-called ‘benign’ gynaecological conditions are particularly overlooked, despite the life-changing and often life-limiting toll they take on those affected.

These conditions include endometriosis, fibroids, menstrual conditions, infertility and subfertility, urogynaecological problems and obstetric fistula, among others. Forthcoming RCOG research [2] details how, overall, morbidity for women and girls due to so-called ‘benign’ gynaecological conditions outweighs the combined morbidity from malaria, TB and HIV/AIDS in low and middle-income countries. This demonstrates the scale of the burden of gynaecological disease and the urgent need to afford it the same priority given to maternal mortality and diseases such as malaria, TB and HIV/AIDS.

To address this enormous unmet need, gynaecological health should be mainstreamed throughout the FCDO’s SRHR programming and prioritised in its healthcare programming more generally. This requires a change of perspective among policy makers to view women beyond their roles as mothers and address their health throughout their life course. The RCOG has put this life-course approach into practice in our Gynaecological Health Matters (GHM) programme. Together with in-country partners and with national government endorsement, we are delivering essential gynaecological skills training to nurses and non-specialist doctors in Bangladesh. With this focus on task shifting, the GHM programme is responding to the unmet need for quality gynaecological health care at the primary level in Bangladesh.

Replicating this life course approach would help to improve girls’ and women’s health and quality of life. As such, it is also key to achieving the FCDO’s objectives of educating, empowering and ending violence against women and girls. Menstrual disorders are strongly associated with girls’ absenteeism, which over time has a significant impact on access to education and confounds pre-existing gender disparities in opportunities for economic security and autonomy [3]. Women also disproportionately shoulder the ‘social burden’ and exclusion associated with infertility, with infertile women facing a higher risk of intimate partner violence [4].

The FCDO’s programming is notable as well, compared to other donors, in its support and advocacy for access to safe abortion, an often neglected SRHR intervention. Mainstreaming safe abortion services and post abortion care is essential to reducing maternal morbidity and mortality. Unsafe abortion remains one of the leading causes of maternal mortality worldwide [5]. The risk of dying from an unsafe abortion is highest for women in Africa, where nearly half of all abortions happen in potentially dangerous circumstances [6].

The importance of safe abortion care is rightly recognised in the FCDO’s approach to Ending the Preventable Deaths (EPD) of Mothers, Babies and Children by 2030 [7]. However, FCDO programming does not sufficiently invest in telemedicine and self-management for abortion, as an additional safe pathway which can increase patient access and choice. Guidance from the RCOG [8,9], the WHO [10] and other authorities on clinical standards all affirm that telemedicine and self-management of abortion are safe and critical in expanding access to quality abortion care. These service delivery models reduce transport costs, increase privacy and enable abortions to be performed earlier in the pregnancy. Patients’ participation in their own healthcare affirms their bodily autonomy and mitigates the stigma around abortion. Moreover, telemedicine and self-management afford more equal access for marginalised groups including those living in rural communities, survivors of gender-based violence, LGBTQ+ people and people with disabilities, among others. FCDO programming on abortion should ensure that healthcare providers and health systems more broadly are supportive, equipped and willing to care for individuals opting for a self-managed or telemedical abortion. By investing in telemedicine and self-management, in addition to other abortion service delivery models, FCDO programming would respond to contemporary best practice in abortion care, increase patient choice and address the unmet need of those who face the highest barriers to quality abortion care.

The principles of self-management and telemedicine should also be applied in other areas of SRHR programming. Self-collection of blood or swab samples is an increasingly important part of programmes for the prevention and treatment of HIV and STIs around the world [11]. Similarly, cervical cancer prevention programmes are beginning to adopt self-sampling as part of their screening apparatus. This approach expands the reach of screening programmes and, with the right guidance and referral pathways, can dramatically improve cervical cancer prevention and treatment outcomes. As with self-management for abortion, these service delivery models improve health outcomes by providing more pathways to SRHR care. They help tackle stigma around these areas of SRHR and normalise the testing process, as patients integrate it into their regular routine of healthcare at home.

2. How effective is the FCDO's work on sexual and reproductive health in support for the provision and delivery of:

a. contraceptive supplies and healthcare services

b. family planning education and information programmes to communities

c. information programmes to tackle practices that damage the sexual and reproductive health of women and girls, such as FGM

The RCOG welcomes the commitment of the FCDO to supporting efforts to end the practice of FGM. In light of the increasing incidence of FGM being performed by doctors and other healthcare providers, particularly in countries such as Egypt, our new programmatic work seeks to equip doctors with the knowledge, skills, competencies and attitudes to help eliminate this practice. As influential figures in their communities, doctors and healthcare workers have a key role to play in eradicating FGM and promoting the sexual and reproductive rights of women and girls. Medicalisation provides a false legitimacy to FGM practice: families and individuals involved in FGM perceive healthcare workers as doing no harm and that their involvement shields them from legal consequences. The FCDO should seek to complement its existing support to FGM and gender-based violence programmes by collaborating with medical bodies and colleges, such as the RCOG, who can mobilise large global networks of healthcare professionals to tackle the rising medicalisation of FGM.

Health workers have an important role to play as advocates to influence attitudinal change and reforms across a range of SRHR issues. Including heavily stigmatised areas of SRHR, such as abortion, into mainstream curricula for health-worker training is an important step towards the normalisation of SRHR care. The RCOG’s Making Abortion Safe (MAS) programme advocates for the inclusion of abortion in mainstream healthcare training and education. The mainstreaming of abortion education is a key finding and recommendation of the MAS programme’s research into the stigma facing providers and forthcoming guidance to be published in 2023 to support healthcare professionals and decision makers to tackle stigma. To tackle stigma and mainstream abortion care, the MAS programme has supported healthcare professionals to work with other healthcare professionals and decision makers as ‘SRHR Champions’ to advocate for reforms to improve curricula and increase access to quality abortion services in Nigeria, Zimbabwe and Rwanda.

d. maternity services and support for new-borns, including ending preventable deaths

The RCOG welcomes the FCDO’s commitment to strengthening the health workforce as part of its Ending Preventable Deaths agenda. Skilled medical professionals play an essential role in the delivery of universal and comprehensive sexual and reproductive health, including maternity services. However, FCDO health workforce programming would have increased impact by working with health workers across cadres, rather than focusing on community and primary care.

The RCOG’s global health programmes provides examples of approaches that deliver training to multiple cadres of healthcare professionals to promote task-shifting and sharing. As described in our previous response, our Gynaecological Health Matters programme is mainstreaming gynaecological skills and knowledge by training nurses and non-specialist doctors in Bangladesh. We have also applied this task-shifting principle in our programme’s strengthening essential and emergency obstetric skills for health workers. These programmes are built on the knowledge that task-shifting and sharing across cadres and strengthening the skills of multi-disciplinary teams of healthcare professionals to provide obstetric care allows patients to access quality SRHR and maternity care, when they first enter the health system.

3. How could the FCDO target the use of funding for sexual and reproductive health programmes more effectively?

A discussion of the effective use of funding for SRHR cannot begin without highlighting the devastating impact of cuts to SRHR programmes in the last few years. Occurring at the worst possible moment, when health services were already under enormous pressure from the global pandemic, there is no doubt that these cuts seriously jeopardised the health and wellbeing of women and girls globally. Estimates suggested that cuts to family planning in the year 2021-22 alone could directly result in 9.5 million fewer women and girls having access to modern methods of contraception, meaning 4.3 million more unintended pregnancies, 1.4 million more unsafe abortions and a possible 8,000 more avoidable maternal deaths [12]. These statistics are even more shocking when you consider every two minutes a woman dies during pregnancy or childbirth globally [13].

There is an urgent need for the FCDO to return stability, longevity and transparency to its budget for SRHR. Prior to the pandemic, UK spending on SRHR constituted 4% of the aid budget [14], around £500 million, per year. A new FP2030 commitment to restoring this spending every year for the next three years (2022 – 2025) presents an opportunity for the FCDO to help regain lost momentum towards universal comprehensive SRHR and to return to its position as a leading and reliable donor. This funding should be a comprehensive investment, including interventions addressing the burden of gynaecological disease as a part of a life-course approach, and strengthening and educating the health workforce as foundational to quality SRH care. It is also important that this commitment is a financial target rather than focused on user goals to ensure that the UK’s contribution is centred on women and girls’ choice and bodily autonomy, as imagined by UN SDG 3.7.1 indicator [15].

The announcement of funding for a new SRHR programme [16] is welcome but it is important that the UK Government continues to also invest in sustainable SRHR supply chains. Sexual and reproductive rights cannot be realised without available and affordable reproductive health supplies. 40% of the world’s contraceptive supply is provided by UNFPA, reaching approximately 20 million women and young people every year [17] but, in 2021, UK funding to UNFPA Supplies faced an 85% cut [18], putting immense pressure on global SRHR supply chains.

Does the FCDO's new global Women and Girls strategy sufficiently address sexual and reproductive health?

We are pleased to see sexual and reproductive health and rights recognised as essential to the FCDO’s ambitions for gender equality. Bodily autonomy is the foundation upon which women and girls are able to exercise their rights, a point strongly made by the Minister for Development in his foreword.

However, resurrecting the problems of the 2022 International Development Strategy, the Women & Girls Strategy’s approach to SRHR continues to be limited by the framework of the ‘Three Es’ of education, empowerment and ending violence. A new expanded definition of empowerment to include ‘championing health and rights’ suggests that this criticism has been partially heard. Still, the opportunity to provide sufficient detail on the FCDO’s ambition for SRHR is lost by shoehorning it into the same bracket as the not insignificant projects of women’s political, social and economic empowerment. In comparison, SRHR stands in its own right as one of four ‘interlinked foundations’ of the former Department for International Development (DfID)’s 2018 Strategic Vision for Gender Equality [19].

Framing SRHR as an issue of empowerment in the Women & Girls Strategy means that it is not only paid insufficient political attention but inappropriate political attention. The fundamental challenge facing universal SRHR is not individual capacity but structural inequalities which mean that the poorest and most vulnerable people bear a disproportionate burden of poor sexual and reproductive health. Again, the approach of DfID’s Strategic Vision is exemplary, recognising that ‘the challenges that poor girls and women face are complex, deep seated and interlinked’.

The focus on SRHR as a ‘long-term’ development issue is a promising change of tack from the sudden and devastating cuts to SRHR funding in 2021. Investing in SRHR is not only important for ensuring access to life-saving services now but is also essential to unlocking the social, economic and political agency of women and girls to make decisions about their futures. However, without a significant multi-year financial commitment to SRHR such as that suggested above, this remains an empty promise.

Finally, we welcome the Strategy’s focus on promoting ‘neglected’ SRHR issues including safe abortion. This brings the Strategy closer to advancing and implementing the Guttmacher Lancet’s definition of comprehensive SRHR [20]. However, as discussed above, the Strategy would benefit from taking a life course approach which views women beyond their role of mothers, including addressing the significant burden of gynaecological disease affecting women and girls around the world.

You can download a PDF version of this position statement here.