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Deadly remedies: A lonely choice

7 Dr San Channa

How unsafe abortion is threatening the health of vulnerable garment workers in Cambodia

In her myrtle-green surgery scrubs, Dr Sann Channa strides purposely through the entrance of the Phnom Penh Municipal Referral Centre and into the women’s department. She passes a heavily pregnant woman, hands draped across her belly, and a nervous-looking couple and beckons me into her office.

A doctor for 25 years and now head gynaecological surgeon at the hospital, Channa doesn’t mince any words, she launches immediately into an account of a difficult abortion she recently performed.

Content image - Phnom Penh Post
Garment workers in Cambodia. Photo by Reuters

“Just a few days ago a young woman originally from Takeo province, Mali*, came in, she was working in a factory on the outskirts of town. She’d fallen pregnant and had been afraid to tell anyone, she wasn’t married, so she bought what she thought was a medical abortion pill at a pharmacy close to the factory she works at. They’re called ‘Chinese Pills’.

 “When Mali came in she was bleeding heavily, she had haemorrhaged, but the pill she had taken had also not aborted the embryo, so we had to perform another abortion.”

She had serious anaemia, a common condition among factor workers, and had not been consulted about her medical history by the pharmacy.

Around 100 women every month seek further treatment for complications at the referral hospital every month after taking a ‘Chinese pill’, the colloquial moniker given to illegal abortion medication, Channa says. Of these, 80 per cent tell her they work in the garment factory sector.

The pills are often counterfeit products made up of either low doses of the (legal in Cambodia since 2008) abortive drugs Mariprist or Medabon (a product, containing mifepristone and misoprostol, that induces medical abortion), nothing at all, or dangerous, toxic chemicals.

“We also often see women after a surgical abortion has gone wrong – where they have gone to a backyard clinic or tried to abort the embryo themselves…we see some pretty severe infections…I’ve never witnessed a death but if they did not seek further care at a hospital they could bleed to death or die from the infection, not to mention the trauma suffered. But mostly, we are seeing women that have taken this pill.”

What is most crucial, she says, is that at the illegal clinics and pharmacies there was usually a complete absence of trained, qualified medical practitioners, and that women, like Mali, with underlying medical conditions, were being sold Medabon, Mariprist and counterfeits.

“A medical check is essential. Many factory workers have anemia [44 per cent says a 2010 Cambodian Demographic Health Survery], poor nutrition, poor general health…ectopic pregnancies [an extra-uterine pregnancy outside the womb or uterus] are a huge concern…they can have heavy bleeding and ruptured fallopian tubes. If they go to a legal provider they would be screened for this. This Chinese pill is very dangerous…if they do not seek further care once a complication has arisen they could die.”

The World Health Organization (WHO) cites one of the major hazardous features of unsafe abortions as being the lack of immediate intervention if severe bleeding or other emergencies develops during the procedure, along with the absence of follow up care and counselling.

According to the WHO, one in 10 pregnancies worldwide end in an unsafe abortion, while 98 per cent of these occur in settings with limited resources – such as Cambodia. Around 13 per cent of maternal deaths worldwide are due to unsafe abortion – in 2008, 47 000 women died from unsafe abortion complications.

It’s not surprising, then, that garment factory workers are one of the most vulnerable groups when it comes to sexual and reproductive health, along with those working in the sex and entertainment industries. According to experts in Cambodia, there has been an alarming increase in the amount of female garment factory workers turning to illegal abortions – in particular illegal medical abortions, just like Mali.

The Reproductive Health Association of Cambodia (RHAC) estimate between 85 to 90 per cent of the garment factory workforce to be young women between 18 and 25, with many of these migrating from far flung provinces into an urban environment for the first time.

According to RHAC’s Work Health program manager, Dr. Rahman Sammrith, last year around 1000 factory workers received post abortion counselling and care at RHAC’s clinics – a significant increase from last year, although both he and Marie Stopes Cambodia technical support manager Melissa Cockroft say studies have been anecdotal and expressed a need for more scientific, peer reviewed research.

Garment factory workers have low literacy rates, work long hours, have limited free time and can not afford transport to registered health services, making the option of taking a “quick fix”, cheaper pill more alluring. According to Channa, women were reluctant to take legal abortion such as Medabon because a number of pills had to be taken consecutively and it had to be inserted in the vagina.

A CARE Cambodia report, Sewing a Healthy Future in Cambodia, states that the garment factory worker, “away from her village and the watchful eye of her family is at risk of abuse and exploitation…not likely to be ‘street wise’ or to have negotiation skills needed to safeguard their sexual health.”

The cultural and traditional barriers that lace Cambodian society still hold sway over many young garment factory workers – the social stigma attached to being unmarried and sexually active means many will remain silent about unwanted pregnancies, and will choose not to seek advice from friends, families or health workers.

Cambodia has one of the most liberal abortion laws in the region (it is still illegal in Myanmar and Laos: in the former it is only permitted to save a woman’s life while in the latter there is no explicit exception to save a womans life, while in Thailand there was more leeway, with abortion permitted in cases of rape, fetal impairment and recognising an exception to preserve a woman’s mental health) having legalised the procedure in 1997. Women can have a medical abortion up to nine weeks and a surgical abortion up to 12.

But a number of country-based charities are calling on garment factories to take responsibility for wide-ranging RHS services, from education to providing contraceptives such as IUDs and implants, training in administering medical abortions and referrals to legal, registered health clinics and hospitals.

“If compared with other countries Cambodia’s policies are actual quite “liberal” and advanced, but then implementation and service availability, as well as stigma are all still barriers to access, despite the legality and policies in place,” Cockroft says.

In 2010 Marie Stopes Cambodia embarked on a two year project with the International Labour Organisation (ILO) and Better Factories Cambodia (BFC) to improve sexual and reproductive health within 20 factories which wound up last October.

It has been one of only a handful of projects directly addressing the sexual and reproductive health of garment factory workers. Twenty ‘peer educator’ workers were trained in each factory to boost knowledge and practice of family planning services amongst staff and the program yielded good results, say the project managers.

Pang Sreymom, 30, is one of those educators. With her fire-engine red lipstick and polished appearance, she’s a bright antidote to the surrounds – the dusty, litter-strewn National Highway 4, outside the gates to her workplace, who supply around 500,000 garments per month to apparel heavyweights such as Adidas and GAP. The factory she works for is one of the few, she says, to embrace Marie Stope’s reproductive health program: “one of the good ones.”

“Most of us live together in rented houses out here so we can share this information, get the information out there…abortion stigma remains one of the biggest hurdles to access safe abortion care,” she says.

Marie Stopes project manager Kun Chanthorn says it was hard to gain the trust and support of factory managers and even to engage peer educators, many of whom were on casual rates or contracts and wanted to work as much as possible, not having the time to attend training sessions.

“Most of these workers had been unaware abortion is legal in Cambodia, so they’re going to secret places or somewhere a friend has referred, a backyard clinic...”

Em Sreymom, who works alongside Chanthorn, agrees.  “A lot of female workers have a lot of trouble with unsafe abortions,” she says, adding that incomplete abortions are a particular problem.

“One girl said she had a surgical abortion in an extremely unclean facility, had no counselling, got sick and went back. They told her “you’ve just had sex again and fallen pregnant again.” They didn’t tell her it was incomplete. This happened to her several times before she came to us – she also paid for it each time”.

Another worker Marie Stopes interviewed said she had taken a ‘Chinese pill’ bought from a pharmacy, that it had not worked and she had suffered profuse bleeding before having to undergo a surgical abortion. She had to take three days off to recover – spending two months worth of wages on treatment and transportantion.

Along with its peer education service, Marie Stopes also run seven clinics in Phnom Penh where women can access family planning advice, contraception,  and safe medical and surgical abortion (for around $25) and are in the process of setting up a clinic close to the airport, where a large number of Phnom Penh’s garment factories reside.

“Generally at our clinics, we have very few cases of incomplete abortions but if we do, they can come back and it is free of charge. These other places [are] taking advantage of women or don’t know what they are doing in the first place…” says Cockroft.

The workers in the factories Marie Stopes do not work with (BFC monitor some 300-odd factories, not to mention the possible hundreds of other sub-contractor factories) could have worse conditions and “a greater need for our services”, she says.

Cockroft says Marie Stopes now plan to use a chunk of AusAid funding through a Partnering to Save Lives grant to continue their work with factories, “hopefully with some of the more vulnerable ones, the ones not monitored by BFC.”

Rahman says RHAC are currently partnering with Marks & Spencer on a sexual and reproductive health peer education program in 16 factories in Preah Sihanouk province and Phnom Penh, due to wind up in October.

A new service for factory workers, HERProject, covering nutrition, health and reproductive care, will launch in the coming months – a partnership between RHAC and ILO.

Rahman could not confirm whether it would cover abortion services or referral, however, a sensitive area for RHAC, who receive the majority of their funding and technical support from USAID, which imposes a “no abortion” ban on foreign aid. The 1973 Helms Amendment to the US Foreign Assistance Act restricts funding for abortion overseas – even in countries where abortion is legal.

Andrea Roos, a spokeswoman for clothing chain H&M told 7 Days that ILOs “Better Work” would collaborate with HERProject in Cambodia, “focusing on women’s health” but remained equally as unclear as to which reproductive health services would be included and to what extent the brand would be involved.

Em Sreymom remains adamant that the brand and buyers hold as much responsibility as the government.

“The buyer holds real sway, they can spread out information to other buyers – no factory wants to risk their reputation amongst the brands [and be boycotted]. All the factories I’ve dealt with…if the buyer asks them something they will generally try to follow.”

Although Prakas 330, of Article 242 of Cambodia’s Labour Law stipulates a garment factory with over 50 employees must set up an infirmary, there are not outlines of what services that infirmary must provide.

“We know that these services will improve worker productivity, it’s to the advantage of the factory… logistically it’s so hard for NGOs to arrange visits, go back and for the between managers, squeeze a day long training session into a 45 minute lunch break – it would make more sense and be better for the factories if they adopted it themselves, ” Sreymom says.

Cockroft says large factories in Vietnam had adopted it into their program and it had made great strides, with doctors and midwives on permanent standby.

Secretary General of the Garment and Manufacturers Association of Cambodia (GMAC), Ken Loo, disagrees.

“Why should the onus be on the factory? That’s nonsense. They have a responsibility as an employer not a counsellor…and the brands – they are certainly not responsible in any way for family planning, sexual and reproductive health.

Workers can take medical leave for that. The infirmary is for work related accidents,” he says.

Reducing the maternal mortality rate of Cambodia is one of the top priorities of the Cambodian Ministry of Health, and Sreymom believes an amendment of the labour law, to include reproductive health, should be an action they commit to, along with a boost in funding for an increased number of practically located sexual and reproductive health services.

Rahman agrees: “I want to see all factory workers receive reproductive health services inside the infirmaries…its much better for all involved, so definitely, yes, I want to see it written into the labour law.”

GMAC, Loo says, “would surely not be the ones to initiate such change.”

Leng Tong, the director of the occupational health and safety department of the Labour Ministry, admits the ministry had not considered writing RHS into the legal framework.

“We do not work for reproductive health for workers…there are [already]some organizations and NGOs taking care of that,” he says.

Tong says it is up to the health ministry to advocate and promote family planning and contraception.

Next week, Cockroft will travel to Kuala Lumpur for the 2013 Women Deliver Conference – one of 100 Young Leaders to win a scholarship to attend. The event brings together health and finance leaders from across the world, policy leaders, politicians, ministers and development experts and global media groups. Safe and Legal Abortion is one of its session themes.

“I’m passionate about the sexual and reproductive health of garment factory workers, as I am for all Cambodian women, as I believe it’s so important for women to have knowledge and information to be able to choose if and when it is right to them to have children,” she says. "When it comes down to it, if a woman wants an abortion, regardless of socio-economic status she will always find a way to get an abortion...This is why it is so important that we try to ensure that women have knowledge and access to safe abortion services."

CARE, who the ILO and Marie Stopes have said contributed to sexual and reproductive health programs within garment factories in Cambodia,  declined to comment for this feature. Levis, The Ministry of Health and AusAID could not be reached for comment.

*Names changed to protect the subject’s anonymity.
Additional reporting by Sen David and Mom Kunthear



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