1.3. Challenges and Gaps 2. EAST AFRICA ........................................................................................................................................................................................... 162

1.3. Challenges and Gaps

Throughout the Decade, countries faced challenges in fulfilling women’s right to health and reproductive health. Even though countries have introduced laws and policies, the slow progress in publishing laws in legal gazettes or implementing decrees has created gaps within legal frameworks, leaving women unprotected. In Chad, for example, discussion on the decree of application for the country’s 2002 Reproductive Health Law delayed adoption until 2018.1101 Prior to this, the legality surrounding abortion was unclear, resulting in clandestine abortions, which contributed to Chad’s high maternal mortality rate.1102 A lack of awareness of the law among medical and judicial professionals as well as women themselves also prevent women from accessing legal protection.

Access to free safe abortion remains a gap with regard to strengthening and protecting women’s health and reproductive rights. Across the Central African region, access to abortion varies. Despite ratification of the Maputo Protocol, Congo Republic continues to criminalise abortion outright.1103 Rather than seeing this as a health matter, countries tend to regulate abortion through their penal codes, criminalising the act with exceptions. Chad’s 2017 reform of its Penal Code allows abortion in line with the Maputo Protocol. However, it is noted that gaps remain. Under Article 358, authorisation of abortion “must be issued by the Public Prosecutor’s Office after certification by a doctor on the facts.”1104 Rural women in Chad lack access to medical and judicial authorities. In an emergency, this poses a serious threat to a woman’s life.1105 In Equatorial Guinea, abortion is permitted in cases of rape and threat to the mother’s life but is subject to spousal consent.1106 Such requirements could pose an unnecessary barrier to women seeking safe abortion. Sometimes, health professions remain unaware of the law concerning abortion. In DR Congo, the shift from outright criminalisation to being legally permitted represents a challenge in spreading awareness to legal and medical authorities. A lack of understanding or resistance to change can still result in ad hoc application of the law, affecting women’s rights.1107 Not all countries offer access to abortion in line with all of the conditions laid out in the Maputo Protocol. Burundi, for instance, allows abortion only in limited circumstances and does not allow abortion in cases of rape.1108 In 2016, the CEDAW Committee noted that in Burundi “45 per cent of incarcerated women are serving sentences up to 20 years of imprisonment on conviction for abortion and infanticide.”1109

Although many countries have introduced policies and programmes concerning health education, there continues to be limited availability of comprehensive education on SRHR and family planning services. In Gabon1110 and Equatorial Guinea,1111 concerns have been raised concerning the lack of services and appropriate sexual education as well as the low use of modern contraceptives and high rates of teenage pregnancy. In Burundi, the lack of education concerning modern contraceptive methods is a challenge.1112 In Chad, lack of knowledge about reproductive health is accompanied by women’s lack of agency concerning decisions over her own health; frequent and early pregnancies; a higher HIV prevalence rate for women; and the continuation of customary practices that are harmful to reproductive health such as genital mutilation.1113 Traditional attitudes surrounding woman’s reproductive choices, including the informal need for the husband’s or family consent, also represent a challenge to fulfilling women’s health rights.1114

Additionally, the availability of accessible, quality and affordable health care also present a barrier to women receiving reproductive care. In Burundi, the most frequent problems cited include lack of funds for treatment (64%) and distance to the health facility (34%).1115 In Congo Republic, disparities reportedly still exist between the level of health care provided in rural and urban areas.1116 While maternal care is free in Chad, it has been reported that women often incur associated hospital costs for beds and medicine.1117 Delivery by a skilled birth attendant can significantly lower maternal mortality rates but not all women have access to this care.1118 In Cameroon, the proportion of assisted births varies, with 40% in the northern regions of the country compared with 97% in the west.1119 These gaps in health care severely undermine women’s health and reproductive rights. Meanwhile, countries in the Central African region experienced sustained conflict during the Decade, which had severe impacts on the provision of even basic social services, with women’s reproductive care suffering. This has also contributed to higher maternal mortality rates. With the aim of reviving its health care system post-conflict, Central African Republic launched its Health Sector Transition Plan in 2015.1120