Health Protection Agency plan youth services to bridge gap in sexual health education

A sexual health education pilot aimed at young people will be launched in Hulhumalé before the end of this year, the Health Protection Agency (HPA) has told Minivan News.

“There is no comprehensive sexual education in the schools,” said the source. “We have to keep talking about these issues, about how to keep young people safe.”

The pilot will provide a comprehensive sexual health and general health service to all young people aged 10-24 years old.

According to the agency’s Reproductive Health Unit (RHU), the the project will attempt to bridge gaps in sexual and reproductive health services for young people.

A member of an established health service provider, who wished to remain anonymous, highlighted age-appropriate guidelines as key barriers to sexual health education.

The comments come after the body of a new-born baby was discovered in a house in Maafanu earlier this week. Local media reported that the 18-year-old mother, currently in police custody, committed infanticide after having hidden her pregnancy.

National Guidelines

The national guidelines issued by the Ministry of Health and Gender prohibit some elements of sexual health education – including condoms and safe sex – until students are 18-years-old.

“There is a standard which is maintained by the health sector. There are a lot of cultural and religious barriers in providing this information,” the source told Minivan News.

“Unless those issues are not tackled, the stigma in accessing [health education] will not happen.”

Reticence in the health sector is mirrored in the family sphere, argued the source, who stated that family members are reluctant to speak candidly with their children about sexual health.

“There are some views of parents that if you talk about sexual health, they might go and do it.”

With no accurate information from schools or parents, the student will often turn to peers or the internet for support on sexual health, noted the source, which results in the rapid spread of mis-information.

Religious barriers

Under the 2008 constitution the Maldives is a 100 percent Muslim country, with national guidelines surrounding sexual and reproductive health being strongly influenced by religion.

A report conducted by the Department of National Planning in 2013 concluded that religious beliefs had been the reason behind an increase in trends such as a preference for home schooling, refusal of vaccination and other medical services for women.

Expressing a similar view, the health sector source noted that religion had contributed to some of the barriers in delivering sexual and reproductive health education.

“That’s a huge barrier actually on sexual health education, because there’s certain beliefs on providing information, or on family planning, on safe abortion,” stated the source.

“They [religious scholars] have a lot of myths related to sexual reproductive health.”

The source suggestion that there is support for the assimilation of religion into sexual health education delivery, but that disagreements between religious scholars had meant that progress was slow.

Next steps

The RHU project is underpinned by the imminent release of their new guidelines, National Standards for Adolescent and Youth Friendly Health Services for Young People.

These guidelines outlines the key standards for health education for all young people aged 10 – 24 years, ensuring that they will “enter the productive age in the fullest possible wellbeing.”

Noting the closure of previous similar projects, such as the Youth Health Café, the RHU noted that there are a number of difficulties in launching a new healthcare service.

The RHU source also wished to remain anonymous, reflecting the strong emotions provoked by discussion of sex education.

“Convincing people to initiate something in health facility is not easy,” they stated.

“It will be difficult. At present it is very difficult, unless the person is coming seeking the services it is difficult.”

When asked if they felt that young people are getting the right information at the right age, RHU representatives responded with a firm “no”.

“Not all. They are not getting that information. As far as access, there is no access.”

Issues regarding a lack of support services for sexual and reproductive health in the Maldives have been well-documented in the past.

A report entitled ‘Maldives Operational Review for the ICPD Beyond 2014‘, carried out by the Department of National Planning (DNP), claimed that incidents of infanticide and unsafe abortions are symptoms of a lack of sexual education in young Maldivians.

The report identified, “clear indicators of the imperative need to provide access to information on sexual reproductive health and reproductive health services to the sexually active adolescents


“Social stigma, religious and social culture” hinder women’s sexual health, says Hope for Women

Young women’s sexual health is being compromised by “social stigma, religious and social culture,” argues Fathmath Nazeefa, Advocacy Officer at local NGO Hope for Women.

According to Nazeefa, many young Maldivians refrain from accessing the limited sexual health services due to these societal pressures.

“It is apparent in many cases we are lacking information in the family-planning area, early sexual engagements, and in gender stereotyping, which actually makes women to go ahead with child bearing practices even though that is not in their best practice,” Nazeefa told Minivan News.

Her comments came after the body of a new-born baby was discovered in a house in Maafanu yesterday. After local media reported that an 18-year-old committed infanticide after having hidden her pregnancy, police have today confirmed the girl in question was arrested this afternoon.

After being taken into custody at around 2:20pm, the girl’s will be detained for up to fifteen days pending a court appearance.

Nazeefa expressed particular concern over a lack of sexual health education for young women which prevents them from making informed choices.

“To prevent this, we need to educate the young minds starting from adolescents on human anatomy, reproductive health, and build their capacity to protect themselves from being sexually exploited.”

A lack of sexual education, argues Nazeefa, is “depriving [women] of their sexual rights and human rights as well.”

“The ultimate objective has to be the empowerment of girls and women so that they make the right choices,” she concluded.

Rise in Infanticide – DNP reports

Yesterday’s news of the abandoned baby girl – discovered after the mother was forced to seek medical treatment by her family – has brought attention to the issues surrounding sexual health services available to young women.

Local media reported yesterday that the 18 year-old gave birth on her own in the family bathroom, with family members unaware of her pregnancy.

According to one family member, the girl didn’t admit to giving birth – even during a doctors appointment arranged by her family.

“However, doctors kept questioning her about her marital status,” a young female member of the family told local newspaper Haveeru.

According to Maldivian law, the repercussions for fornication out of wedlock is flogging for both the man and the woman involved.

The Maldives is a 100 percent Muslim country, and it’s justice system is based on a hybrid of common law and Islamic Sharia.

Some critics of the justice system have also highlighted the lack of accountability for men in cases of extra marital fornication.

“These women are tainted for life and forever looked down upon. There were a couple of men too, but the islanders did not react in the same way against the men. They seem to be more easily accepted back into society, their sins are generally forgiven or forgotten in time,” a former court official, who wished to remain anonymous, had previously told Minivan News.

Issues regarding a lack of support services for women with unwanted pregnancies in the Maldives have been well-documented in the past.

A report entitled ‘Maldives Operational Review for the ICPD Beyond 2014‘, carried out by the Department of National Planning (DNP), claimed that incidents of infanticide and unsafe abortions are symptoms of a lack of sexual education in young Maldivians.

The report identified, “clear indicators of the imperative need to provide access to information on sexual reproductive health and reproductive health services to the sexually active adolescents and youth population.”

Infanticide also appears to be increasing, as demonstrated by media reports cited in the study, which included several new born babies and few premature babies abandoned in parks, buried in secluded places, or thrown into the sea.

“These are clear indications for the need of life skills programmes and reproductive health education,” the study suggested. “Access and utilisation of contraceptives to avoid unwanted pregnancies must also be advocated to minimise these issues.”


Maldivian youth need access to sexual reproductive health education, services: Department of National Planning

Maldivian youth need sex education and access to reproductive health services, given high numbers of unsafe abortions, rising infanticide, as well as increasing risk factors that contribute to the spread of sexually transmitted infections and HIV/AIDS, a Department of National Planning study has found.

The study examined how much human development progress has been achieved in the Maldives in terms of population and development, reproductive health and rights, gender equity, equality and empowerment of women as well as education during the period 1994 – 2012.

The thematic Programme of Action (PoA) goals were established during the 1994 Cairo International Conference on Population and Development (ICPD) and adopted by 179 participating governments, including the Maldives. Thus, the “Maldives Operational Review for the ICPD Beyond 2014” study was conducted under the supervision of the Department of National Planning (DNP) in collaboration with the United Nations Population Fund (UNFPA).

Overall the study found that the Maldives has “accomplished remarkable progress” in achieving the ICPD PoA goals, with “impressive advancements in all development areas… and notable achievements in sexual and reproductive health.”

However young people and women continue to lack access to quality services, particularly in regard to sexual and reproductive health, which is putting their health at risk.

Youth comprise the largest population group in the Maldives and “[with] the number of young people entering their reproductive years on the rise, special attention to ensure that adolescents and youth are provided with sufficient knowledge about their anatomies, sexual and reproductive health, contraceptives and sexually transmitted diseases is needed,” stated the study.

“Access to contraceptives is limited to the married population despite overwhelming empirical evidence suggesting the need to provide contraceptive information and access to the youth population,” the study noted.

“Information must also be provided on the risks of getting pregnant in young age and of unsafe abortion,” the report continued.

“Simultaneously, it is also essential to establish more comprehensive and confidential reproductive health services which are more accessible and affordable,” the study found.

The report repeatedly noted that although information regarding reproductive health, HIV and sexually transmitted infections (STIs) are technically “available to everyone regardless of age, gender and marital status…access to reproductive health services are still limited to the married population.”

However, even the married population is not always ensured access to accessible, affordable and confidential reproductive health services, according to the study’s findings.

Contraceptive use among married couples is “relatively low”, with “Only 27 percent of married women using modern methods”.

“With regard to reproductive rights, men often control decisions regarding women’s reproductive health, often based on religious and cultural grounds,” the report noted.

“[Furthermore,] the sudden growth of religious fundamentalism and conservative thinking is an emerging challenge, particularly for women and young girls,” the study stated. “There have been increase towards certain trends such as preference for home schooling and refusing vaccination and other medical services for women based on religious beliefs.”

Sex, drugs, and reproductive rights

The report highlighted the “clear indicators of the imperative need to provide access to information on sexual reproductive health and reproductive health services to the sexually active adolescents and youth population.”

High numbers of unsafe abortions – mostly through injections and pills – were noted as “one of the main causes of preventable maternal deaths in the country.”

Infanticide also appears to be increasing, as demonstrated by media reports of “several new born babies and few premature babies found in parks and/or buried in secluded places and/ or thrown into the sea,” said the report.

“These are clear indications for the need of life skills programmes and reproductive health education,” the study suggested. “Access and utilisation of contraceptives to avoid unwanted pregnancies must also be advocated to minimise these issues.”

The lack of reproductive health rights and services for women and girls have also lead to observed increases in non-communicable diseases such as breast cancer and cervical cancers, according to the study.

Meanwhile, male reproductive health issues are often ignored, while “family planning and use of contraception is largely considered a woman’s responsibility.” Therefore, the study recommended strengthening awareness information and access to male reproductive health services.

In order to create the awareness needed about reproductive rights and reproductive health, the report suggested using “Carefully targeted programmes using innovative and youth friendly tools such as social media and text messaging.”

An interrelated issue includes widespread drug use and substance abuse among Maldivian youth, with cases reported to the Maldives Police Services increasing from 195 cases in 2001 to 1,160 cases in 2010, noted the study.

“The high level of drug usage coupled with the increase in commercial sex workers imposes great risks for HIV/AIDS and other sexually transmitted infections and reproductive tract infections,” said the report.

The lack of sexual reproductive health access and awareness combined with risk factors including sharing needles to inject drugs, sexual activities among adolescents and youth, extramarital sex, and commercial sex workers, “could contribute to an increase in the incidence and prevalence of STIs and HIV/AIDS,” the study found.

“It is therefore crucial to educate the population on the risks of STI’s and HIV/AIDS through carefully designed behavioural change communication strategies,” the report recommended. “It is equally important to promote awareness on the availability of voluntary counseling and testing services and contraceptives such as condoms in Male’ and in regional level.”

The report recommended giving special consideration to “identify these high risks groups and provide them with the necessary information, treatment and services.”

Age appropriate sexual and reproductive health education needs to taught in schools to combat the increasing “sexual health illnesses” in the Maldives, according to the Centre for Community Health and Disease Control (CCHDC).

In 2012, CCHDC’s Public Health Programme Coordinator Nazeera Nazeeb revealed that studies have found high risk behaviors – including “unprotected sex, drug and alcohol abuse, homosexuality and prostitution” – are putting young people at high risk of sexually transmitted diseases and HIV.


Couple charged with murder after allegedly aborting, burying five-month old foetus

The Criminal Court has charged a couple from Seenu Atoll with murder after they allegedly aborted a pregnancy and buried the five month-old foetus on the beach of Maradhoo-Feydhoo.

Twenty-one year-old Aminath Shaahee Aalam was 20 weeks pregnant when she gave birth on December 12, 2012, according to local media. Shortly after she gave birth, her husband, 26 year-old Ibrahim Wisam, stands accused of placing the foetus in a plastic bag and burying it on the beach.

Police discovered the foetus buried on a Maradhoo-Feydhoo beach after local witnesses reported a motorist acting suspiciously in the area on the evening of December 14, according to local media. Abortion in the Maldives is illegal unless it is proved the conception is the result of rape, or that the pregnancy is a threat to the mother’s health.

The Prosecutor General’s Office forwarded the couple’s case to the Criminal Court on May 2, however a trial date has not yet been scheduled.

The young married couple from Maradhoo-Feydhoo – an administrative district of Addu City – are both being charged with murder, Criminal Court Spokesperson Ahmed Mohamed Manik confirmed to Minivan News today (May 5).

The prosecution accused Aalam of taking abortion pills, and alleged the couple did not seek medical care during the woman’s pregnancy, labour, or after giving birth to the five month-old foetus.

Police have stated that the buried foetus was found with its heart beating, but later died after being taken to the hospital, Manik explained.

Police said the couple had said they chose to bury the foetus because they did not want to have a child at that point in time, according to local media.

A medical authority in the Maldives informed Minivan News that a five month old foetus would be incapable of surviving outside the mother’s body.

In previous similar cases in the Maldives, a lack of post-mortem services and an absence of visible wounds on the body was observed as making it difficult to prove charges of infanticide without a confession from suspects.

In 2006, the Juvenile Court acquitted a woman from Dhabidhoo island, who police alleged had killed her newborn and disposed of the body in the lagoon, ruling that her three confessions contradicted each other. The woman gave birth out of wedlock in 2008.

Desperate measures

Cases of abortion, infanticide and discarded infants have been widely reported in local media over the past two years, particularly a spate of discoveries over several weeks in May 2011. One foetus was discovered in hidden in a milk tin, while the other was found at the bottom of Male’s municipal swimming pool area.

Later the same month, the corpse of a newborn infant was found discarded in some bushes with underwear tied around its neck.

A further two newborn children were discovered abandoned but alive the same year, and were placed under state care.

In December 2012, a newborn was found abandoned on a pavement in Male’, while in June the same year police recovered the body of a newborn infant buried in the outdoor shower of a house on Feydhoo in Shaviyani Atoll. The baby’s mother was identified as a 15-year old school student, who had allegedly been abused by her stepfather.  The girl’s stepfather was himself later charged with child sexual abuse and premeditated murder.

The 15 year-old meanwhile confessed to an unrelated instance of premarital sex during the police investigation and was sentenced by the Juvenile Court in February 2013 to 100 lashes and eight months of house arrest for the crime of fornication.  At present, the minor will be lashed once she has turned 18.

The girl’s case has garnered international attention and a petition by Avaaz for the government to appeal the sentence and issue a moritorium on the flogging of women for extramarital sex.  The petition has so far reached over two million signatures.

Social stigma

Birth out of wedlock remains heavily stigmatised in the Maldives. An unreleased 2007 study by the International Planned Parenthood Federation (IPPF) found that the stigma of having a child out of wedlock compels Maldivian women and girls to opt for abortions, and while a taboo subject, the practice was found to be widespread.

Some of those interviewed for the study said they knew of girls as young as 12 who had undergone abortions, and each knew at least one person who had terminated a pregnancy.

Abortion is illegal in the Maldives except to save a mother’s life, or if a child suffers from a congenital defect such as thalassemia. Many women unable to travel to Sri Lanka resort to illegal abortions performed by unskilled individuals in unhygienic settings, or even induce abdonminal trauma or insert objects into their uterus.

Other studies focusing on HIV have identified associated risk factors contributing to unplanned pregnancy including high levels of promiscuity and limited use of contraception.

The Centre for Community Health and Disease Control (CCHDC) has described these incidents, as well as the figures detailing an increase in the rate of sexually transmitted diseases, as evidence of a sexual health crisis in the Maldives.

Nazeera Najeeb, who leads the reproductive health unit of the CCHDC, told Minivan News in an 2012 interview that the centre was witnessing an “alarming” increase in cases of underage and unplanned pregnancies, where some girls are getting pregnant “without even knowing it”.

“These unwanted pregnancies are subsequently resulting in more unsafe abortions, baby dumping or infanticide,” she noted.

To curb these perceived problems, Najeeb stressed the need for implementing a comprehensive sex education curriculum in and outside educational institutions to create greater awareness on sexual and reproductive health subjects.

Though the concept of sex education is widely supported by health authorities, including Health Minister Dr Ahmed Jamsheed, efforts to implement such practices nationally have been limited.


Abortion in the Maldives: the untold story

When the strip on the pregnancy test turned pink, 23-year-old Mustafa asked his girlfriend to marry him. Not because he wanted to, but because he believed it was the right thing to do.

She said no.

Aminath, who was 19, replied she was too young to have a child. And so, he told her he would “fix it”.

A few days later, Mustafa learned of a man who charged Rf2,000 (US$155) to perform an abortion. Reassured by two friends who had used him, he set up an appointment in Male’.

“The man gave her three injections and said that within one to four hours, she would start to bleed and it would be very painful and it would be like giving birth,” says Mustafa, his frail voice quivering.

“At this point I was having serious doubts about this guy. He wasn’t a doctor… he was boasting about his abortion activities and the number of girls he had done this to. He said at one point it was almost one every night. The way he said it was without a trace of compassion.”

Mustafa’s description of what followed is harrowing: Aminath was carried back and forth to the toilet, she threw up twice and was writhing in agony. Four hours later, she began to bleed.

As a Muslim country, abortion is illegal in the Maldives except to save a mother’s life, or if a child suffers from a congenital defect such as thalassemia. But anecdotal evidence points overwhelmingly to a high rate of abortion.

“I can count seven of my friends, three girls and four boys. The story was the same,” says Mustafa.

Statistical vacuum

There is scant information available on abortion in the Maldives. No research on the subject has ever been commissioned. But, says Fathimath, 40, a social researcher on youth and women, other statistics indicated that abortion was prevalent.

She points to the discrepancy between the decline in the fertility rate and the low rate of contraceptive use – an estimated 39 per cent – which raised important questions that remained unanswered.

Halfway through the conversation, Fathimath says she herself has terminated two pregnancies. The first time she was 20 and a newlywed. She had been given the opportunity to study in the UK and felt her pregnancy was ill-timed. Her second abortion was more recent: her husband had been cheating on her when she found out she was pregnant.

“At that time, I wasn’t emotionally capable of having a child,” says Fathimath, who had both of her abortions abroad.

The only tidbit of official information that exists comes from the Reproductive Health Survey conducted in 2004. The survey found that despite the absence of reliable data, it was likely that unsafe abortions could be a cause for concern. Three years later, an unofficial report by the International Planned Parenthood Federation (IPPF) reached a similar conclusion.

Interviews with four demographically-diverse focus groups revealed that induced abortions were common among women and girls in Male’ with most ostensibly taking place in unsafe circumstances.

But, the IPPF never obtained government permission to carry out the study and because of the qualitative nature of its research, its findings were never acknowledged or made public, says Fathimath.

The report found that the stigma of having a child out of wedlock compels women and girls to opt for abortions. Two focus groups of unmarried boys and girls asserted that abortion was widespread. Some said they knew of girls as young as 12 who had undergone abortions and each knew at least one person who had terminated a pregnancy.

The discussions further revealed that while abortion was more common among unmarried youth, it was still widespread among married couples. Even within marriage, an optimal family size, economic hardship, infidelity, domestic violence, contraceptive failures and unexpected pregnancy in older women were factors that contributed to the decision.

In one interview, the IPPF spoke to a 37-year-old woman from a poor socio-economic background whose husband suggested she have an abortion. He procured and administered the injections but soon after, the woman fell sick and began to bleed profusely. She consulted a doctor and discovered the baby was still alive; she had to travel to India for a safe abortion.

Honour killings

For those who can afford it, travelling to India or Sri Lanka is an option. But in neighbouring Sri Lanka, where abortion is illegal, the operation is performed by unskilled individuals in unhygienic settings.

One unmarried woman interviewed by the IPPF travelled to an abortion clinic in Sri Lanka when she was 31.

She said she remembered hearing the sound of women crying and the stench of blood. The abortion was carried out on a soiled bed and she was not anaesthetised.

“I felt like a piece of meat; I couldn’t help crying throughout [the process],” she said. Once the abortion was over, she was ordered out of the room despite not being able to physically move.

For those like Mustafa who cannot pay to go abroad, the alternatives are bleak. Abortion-inducing pills and injections administered by amateur abortionists are one recourse while others turn to harmful vaginal preparations, containing chemicals such as bleach or kerosene. Although infrequent, some insert objects into their uterus or induce abdominal trauma.

“It’s difficult to name names but I know prominent women who have had multiple abortions,” says Aishath Velazinee, a well-known campaigner for human rights.

“If a daughter gets pregnant, parents would rather have an abortion,” she says, referring to the shame of pregnancy outside of marriage. “I think it’s appropriate to call these abortions honour killings.”


Using the information gleaned from the focus groups, IPPF concluded that widespread premarital and extramarital sex, high rates of divorce and remarriage (including sex between marriages), and poor access and practice of contraception could lead to a high number of unwanted pregnancies.

All four groups said that despite being illegal, sex outside of marriage was commonplace, especially among young people. Nor was it uncommon for married men to have affairs with unmarried girls.

But disturbingly, the focus groups said that couples preferred not to use contraception. Among the reasons offered included a reluctance to use condoms.

For some, the IPPF discovered, having an abortion was itself a form of contraception. One girl said: “When abortions can be obtained without much difficulty, young people do not want to use contraceptives as those take away the pleasure.”

Under the form of sharia law practiced in the Maldives, both sex before marriage and adultery are offences punishable by flogging. But attitudes towards sex reveal a discrepancy. While it is acknowledged in private that both take place, social norms and cultural attitudes restrict public discussions on the subject. As a result, students are not taught about contraception at school as for many this would be tantamount to condoning sex outside of marriage.

Government policy

Nazeera Najeeb, head of the population division in the health ministry, stressed that it was difficult to grasp the extent of the problem in the absence of official statistics.

“Without that it’s difficult to say exactly what’s happening,” she says.

The health ministry has plans to conduct research into abortion in the Maldives and educate the public about the health risks involved, she says.

“We are trying to create awareness on the disadvantages. At present we are trying to develop some mass media programmes.”

The list of potential health complications associated with unsafe abortion rolled off by Nazeera makes for grim reading: reproductive health infections, infertility, septicaemia, shock and even death.

While students could not be taught about contraception at school, they could be alerted to the dangers of unsafe abortion, she said. In addition, the health ministry could redouble its efforts to promote contraception among married couples.

For Velazinee, however, as long as the government continues to shy away from the sensitive issues that surround abortion, couples will continue to find themselves in the same quandary.

As with the drug epidemic, only government policies that addressed the real picture would help break the taboo, and thus, move the country towards finding a solution, she says. Until a shift in policy-making occurred, she adds, society will continue to be marked by a dualism: a public facade that does not reflect the private sphere.

“We gear policy to the normative standards of being a 100 per cent Muslim country rather than the reality. The government doesn’t want to publicise the availability of contraception for fear the move will be misinterpreted. They don’t want to acknowledge these issues, but the reality is that these things happen.”

The names of all those who have spoken about their personal experiences involving abortion have been changed.