KAMPALA, UGANDA — Ruth, a mother of two, worries that her husband might divorce her.
“I am sad that I am unable to have children for him,” she says. “I worry that when he gets to know, he might leave me.”
The 39-year-old tailor remarried five years ago. She lost her first husband to HIV, and she hasn’t had any children since 2008, when she delivered her last-born child via cesarean section at a public hospital in Arua District in northwestern Uganda.
Two years ago, Ruth, who has HIV, learned that she was sterilized, without her consent or knowledge, when she had that C-section.
“I have been trying to conceive in vain,” she says. “I was told by a gynecologist that my fallopian tubes were cut.”
GPJ reporters in Kenya and Uganda teamed up to tell the complex story of forced sterilizations. Lydia Matata of GPJ Kenya highlights one of the many challenges in reporting this story — finding sources.
Ruth, who asked that only her first name be used, is among an unknown number of women with HIV in East Africa who say they were forcibly sterilized because of their health status. Some say relatives authorized their sterilization without telling them, while others say health service providers threatened to deny them food if they refused the procedure.
In Kenya, a group of those women are suing the government and some health facilities for violating their reproductive health rights. Rights groups hope the outcome of this case will set a precedent for how to compensate victims of forced sterilization.
Apophia Agiresaasi, GPJ Uganda
There are no major legal cases underway in Uganda, says Hannington Mutabarura of the International Community of Women Living with HIV Eastern Africa (ICWEA), but women and rights experts say the problem is as widespread in Uganda as it is in Kenya.
A 2012 report by the African Gender and Media Initiative (GEM) documented stories of 40 HIV-positive women in Kenya who claim to have been sterilized forcibly or after coercion.
Four Kenyan women, together with Kenya Legal & Ethical Issues Network on HIV and AIDS (KELIN) and GEM, have filed a petition against Marie Stopes International, Médecins Sans Frontières (MSF), Pumwani Maternity Hospital, a public maternity facility, and various government officials. One Kenyan woman, together with KELIN and GEM, has filed a petition against MARURA, a maternity nursing home, as well as various government officials.
Both petitions were filed in December 2014, officials with KELIN say.
Several organizations, including UNAIDS, have applied to be enjoined in the cases, according to multiple sources at KELIN.
People involved in the lawsuits say they expect the cases to be heard in court in April and May.
Lawyers selected the five women from the 40 women noted in the report because they had proper documentation that could be used in court, says Saoyo Tabitha Griffith, a lawyer and program manager for sexual reproductive health and rights at KELIN. Those five women are now considered test cases for how courts will respond to women who say they were subject to forced sterilization, Tabitha says.
In Uganda, 20 out of 72 women who reported having been sterilized said the procedure was forced upon them or they were coerced, according to a study published in June 2015 by the ICWEA. For most of the women, sterilization was done when they were giving birth via C-section. Two said they were unaware that they had been sterilized until they failed to conceive years later, the report says.
Forced and coerced sterilization is a global phenomenon. Cases have been reported in countries worldwide including Bangladesh, Cambodia, Namibia, Mexico, South Africa, the U.S. and elsewhere.
In South Africa, 7 percent of respondents interviewed in a 2014 study on HIV stigma said they had been forcibly sterilized. In Namibia, the Supreme Court in 2014 upheld a ruling by a lower court that the government had forcibly sterilized three HIV-positive women. The court held that the practice of coerced sterilization violated the women’s rights.
In Africa, where many communities place a high value on childbearing, some women who can’t get pregnant face discrimination.
Sarah Nakayima, a Ugandan woman who was sterilized without her knowledge in 2013, says her husband might leave her if he finds out that she cannot bear him any more children.
“I can’t tell my husband. He may stop paying my rent yet I have no job,” she says.
Nakayima, who has HIV, says she was sterilized when she delivered her third child via C-section at a public health facility in Uganda.
“I was with my sister at the hospital and I was very sick,” she says. “My sister signed the form.”
Her sister told her a year later that she had been sterilized, Nakayima says.
One of the sterilized Kenyan women, who is referred in court documents as SWK, says she conceived in 2009, according to the petition. During her prenatal visits at a clinic known as Blue House for its blue walls that was run at the time by MSF in Mathare, a slum in Nairobi, a nutritionist told her that if she did not consent to tubal ligation during delivery, she would not qualify to receive food, including cooking oil and porridge. Her consent to sterilization was also required for MSF to pay her hospital bills.
When SWK gave birth at Pumwani Maternity Hospital in May 2010, a nurse gave her a paper to sign before her C-section saying she agreed to undergo a tubal ligation and C-section, court documents say.
Several days after leaving the hospital, according to the petition, SWK went to the Blue House clinic to collect formula milk for her baby. A nutritionist at the clinic asked her to provide proof that she had undergone tubal ligation so she could receive the milk. She went back to the hospital and her card was stamped to show that she had been sterilized.
Tabitha says KELIN is still receiving reports of forced sterilization of HIV-positive women. Some of those women don’t know their rights have been violated, Tabitha says.
Mutabarura, the monitoring and evaluation manager for ICWEA, says forced or coerced sterilization is more common in public health facilities because health workers have a limited time to introduce patients to various family planning options.
Mutabarura says most victims of forced and or coerced sterilization are from impoverished backgrounds. Relatives sometimes authorize their sterilization because they feel the women are not able to take care of many children.
“Poor women all over the world have historically been targets of forced sterilization,” adds Inviolata Mmbwavi, the national coordinator for the Kenya chapter of International Community of Women Living with HIV. “A rich woman living with HIV would not go through that. She would tell the doctors off. These grassroots women are the ones being taken advantage of because they do not know their rights, or they are too intimidated to demand their rights.”
Rukia Nakamatte, a communications officer for the Ministry of Health in Uganda, says sterilizing HIV-positive women without their consent is not a policy of the government.
She says the government plans to investigate claims of forcible sterilization.
“We have set up a team at the Ministry of Health to look at the report then investigations will start,” she says, referring to the 2015 report from ICWEA.
The National Family Planning Guidelines for Service Providers in Kenya, updated in 2010,includetubal ligation as an appropriate family planning method for HIV positive women but emphasize that thorough counselling should occur before the procedure.
“Special care must be taken to assure that every client who chooses this method does so voluntarily and is fully informed about the permanence of this method and the availability of alternative, long-acting, highly effective methods,” the guidelines state in regards to any voluntary surgical contraception for any person.
Marie Stopes Kenya and MSF, in response to accusations made against them in court, say staff at their facilities do not forcibly sterilize women with HIV.
In an email to GPJ, Wairimu Gitau, a communications manager with MSF’s Kenya division, says, “MSF does not wish to comment on this matter which is before the Court; but all the allegations that are made against MSF are denied, and we will respond to in writing through papers, as directed by the Court.”
In a December 2014 statement on their website, Marie Stopes Kenya said it is investigating claims that their staff referred some HIV positive patients to government hospitals for sterilization.
“We are committed here in Kenya, and everywhere where Marie Stopes works, to ensuring that all women are able to exercise their right to choose if, when and how many children they have – with no interference from others, and regardless of their HIV status,” Faustina Flynn-Nyame, the country director said in the statement when the cases were filed in court.
In an email to GPJ, Flynn-Nyame wrote that she could not comment on the case.
MSF leaders say in a statement that three of the women who are part of the legal battle were former patients, and said the organization was reviewing the claims.
The statement says that after a 2012 internal audit MSF reinforced internal procedures related to how information about surgical sterilization is provided to patients, and that patients are now required to take a minimum of three weeks to consider any non-reversible family planning option.
Nakayima, one of the Ugandan women who was sterilized without her knowledge, says legal action should be taken against health workers and relatives who make the choice to sterilize women.
“No woman should ever be sterilized without her consent,” she says.
In Kenya, KELIN and GEM want a declaration from the court stating that the rights of the five women were violated. They’re also seeking, among other things, monetary compensation for the women, and for awareness campaigns and training to be conducted.
“Several of these women’s rights were violated, including the right to the highest attainable standard of health and the right to marry and found a family,” says Tabitha, one of the KELIN lawyers representing the women in court.
Mmbwavi hopes the lawsuits will end forcible sterilizations in Kenya and highlight other violations of sexual reproductive health rights of women with HIV.
“This is just a tip of the iceberg,” she says.
Apophia Agiresaasi, GPJ, translated some interviews from Luganda.