Two HIV-positive Namibian women who allege they were sterilised against their will in public hospitals are seeking redress through the courts, the first of more than 20 known cases, according to the International Community for Women Living with HIV/AIDS (ICW).
The ICW raised the alarm over what it terms forced or coerced sterilisations among HIV-positive women more than a year ago, after hearing accounts of it through its regular forums for HIV-positive young women.
The organisation has since partnered with the legal aid body, the Legal Assistance Centre (LAC), to bring two cases before a judge this year, according to the ICW's Aziza Ahmed.
Another six cases could potentially go to trail this year, and a further 20 are being looked into by LAC and the ICW.
Although the ICW has been made aware of a number of other cases, legal action has been hampered by difficulties in collecting evidence and statements from women involved, who are often reluctant to come forward due to fears that both their HIV status and their inability to bear children will be made public, according to Veronica Kalambi, who sits on the ICW's southern Africa steering committee.
A matter of consent
Since the initial reports came to light, the ICW has conducted fact-finding missions to three of Namibia's 13 administrative regions to document stories from women who have been sterilised, some of whom said they signed consent forms to undergo what was simply listed on their health documents as a "BTL" without fully understanding its implications.
"BTL" is the acronym commonly used for bitubal ligations. Considered a permanent form of sterilisation, the procedure involves sealing a woman's fallopian tubes to prevent pregnancies. Reversals are possible but the procedure is costly and success is uncertain.
"The majority of these women are rural or illiterate, they don't know what 'BTL' means and there is no explanation. Even me, I didn't know what it meant," said Kalambi, adding that for some women, consent forms presented to them in English instead of their home languages were also a barrier to ensuring consent was actually informed.
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The ICW's Saima Moses, who conducted research on the subject in northern Namibia, found some hospitals even had lists for women waiting to undergo the operation. Again, she said, few on the list had any idea what they were in for.
"It's a kind of discrimination," she said. "Nowadays, if you're HIV-positive, you can have a healthy child and it's your right [but] to doctors it's like because a woman is HIV-positive, why should they have a child? [Doctors] assume that child is always going to be sick."
According to Ahmed, a submission was made to the Deputy Minister of Health and Social Services (MoHSS) to investigate cases of alleged 'forced sterilisation', however she has yet to respond.
MoHSS spokesperson, Gladys Kamboo, told IRIN/PlusNews that the ministry declined to comment given the now legal nature of the issue.
In October 2008, IRIN/PlusNews spoke to Dr Rheinhardt Collin Gariseb, the head of Katatura State Hospital in the capital, Windhoek, where the ICW says sterilisations without informed consent have taken place.
According to Gariseb, no incidents were reported to the hospital and that allegations were first brought to his attention through local media reports.
The hospital does offer tubal ligations to women, particularly those who may be on their third caesarean section and therefore have increased the possibility of their uteruses rupturing with another birth, but he maintained that if proper protocol was observed, there would be multiple opportunities for patients to object to an operation.
"It's the duty of the doctor to inform the patient through a translator, if necessary, [about any procedure]. Usually, we use one of the sisters, who takes the patient's consent," he said. "Then when the patient is taken to theatre, the sister hands over the patient to
the doctors and will again verify the procedure for which the patient has been admitted."
However, given the testimonials of women collected by the ICW complaining of the brusque attitude of some health workers, sisters doubling as translators could be cause for concern.
Shantel Ferreira* said she narrowly escaped being sterilised. The HIV-positive mother of two had checked into Katatura for what she assumed was a standard follow-up operation after she gave birth two months early.
Although she said she had asked what the BTL she was slated for was, an overworked nurse told her to sign and that she would tell her later. Eventually, after a power outage minutes before her operation was about to begin gave her the time she needed to find a nurse who, she said, took the time to explain the procedure's repercussions.
The LAC and IWC are still waiting for the trial dates for their first two cases. In the meantime, Kalambi said she has seen a worrying number of HIV-positive women express fears about delivering their babies at public hospitals due to the sterilisation scare.
That, she said, could have serious consequences for mothers and babies due to complications or lack of access to prevention of mother-to-child HIV transmission services.
*not her real name