Sexual and Reproductive Health in Somaliland
Larissa Rodrigues Cimini
Nádya Carolline Silveira
Pedro Ivo Machado de Oliveira
Ruth Amaral Aguiar
Silvia Alonso Vega
When studying about women’s health and menstrual dignity in Somaliland, it is crucial to fully understand these concepts to comprehend how they apply in the reality of Somaliland. Another two concepts that will be used along with the first two are gender based violence and sexual transmissable infections, that will be relevant to the research as a whole.
On that note, the World Health Organization (WHO) classifies women and men’s health separately because they understand that women’s necessities are quite different from men, a result of biological and gender-based differences.
The women’s health is factor of concern for the organization and world in general because they have a big disadvantage by discrimination and socialcultural factors. The main socio cultural factors that affects women are the unbalanced power relationships between men and women; social norms that prohibit education and paid employment opportunities that inevitably creates a relation of dependency with men; an exclusive focus on women’s reproductive role and the constant potential or actual experience of violence – physical, sexual, or emotional.
Along with that, poverty also plays a relevant role in the women’s health scenario. Although it creates barriers for both men and women, poverty affects, for example, feeding practices (malnutrition) and use of unsafe cooking fuels (COPD). Furthermore, women and girls are more vulnerable to HIV/AIDS, which is related to the unequal power relationship between men and women. The lack of information is also relatable in this case. The Somaliland Health and Demographic Survey 2020 declared that only 9% of Somali women aged from 15 to 49 had comprehensive knowledge about AIDS and 57% percent of women aged 15-49 do not think that children living with HIV should be able to attend school with children who are HIV negative.
Another aspect to be included in the big concept of women’s health is menstrual dignity. The UNFPA (United Nations Population Fund) declares that period poverty as “the struggle many low-income women and girls face while trying to afford menstrual products.” With that in mind, it is possible to say that menstruation is intrinsically related to human rights, because when basic tools and effective meanings to manage menstrual hygiene are not provided, such bathing facilities or sanitary napkins and tampons, pain medication and underwear, people who menstruate are not able to manage their menstruation with dignity. Moreover, according to the organization, gender inequality, extreme poverty, humanitarian crisis, harmful traditions, menstruation related teasing, exclusion and shaming undermine the principle of human dignity and deprive them from their human rights. The lack of information about the menstrual cycle, the hormones, what happens in their body, and above all, the normalization of the topic, makes women, trans men and non binary people who menstruate even more vulnerable to sexual transmissable infections and gender based violence against them.
Sexual transmissable infections (STI) can be conceptualized as infections that are spread by unprotected sexual contact. The infections have a deep impact on women’s health. If untreated, they can lead to serious consequences, such as neurological and cardiovascular disease, infertility, ectopic pregnancy, stillbirths, and increased risk of Human Immunodeficiency Virus (HIV). The STIs are often associated with stigma, domestic violence, and affects quality of life. In Somaliland, the Health and Demographic Survey 2020 announced that ten percent of women reported having either an STI or STI symptoms.
The last concept, one of the most important, is gender based violence. It is, by far, the most prevalent kind of human rights violation in the world. According to the Somaliland Health and Demographic Survey, Gender Based Violence (GBV), is any kind of harmful act of physical, sexual, mental, or emotional, that is perpetrated against women and girls. Culturally, Somaliland women are not comfortable discussing domestic violence openly, which is the scenario where the GBV happens more currently. Furthermore, the GBV can lead to depression, anxiety, permanent injuries, post-traumatic stress disorder, sleep difficulties and sometimes death. The survey shows that 12% of women aged from 15 to 49 years have experienced physical violence at least once since. When it comes to ever-married women, 10% of them, from 15 to 49 years, experienced physical violence, and 2% experienced emotional abuse committed by their spouse. Only 22% of them sought help for different forms of violence. The graphic below exposes the situation of gender violence in the country:
Analysing the graphic is how GBV is a constant in the loves of many Somali women – considering that in surveys like this, many women do not share their experiences, so the percentage can be even higher.
With all of that in mind, the following topics will discuss how these concepts reverberate in the life of Somali women, under a lens of international law, the country’s historical, social and traditional background.
The Role of International Law
Sexual and reproductive health rights are grounded in multiple human rights, such as the right to life, the right to the right to health, the right to privacy, the right to education, the right to be free from torture, the right to be free from discrimination, and the right to be free from sexual violence. The Universal Declaration of Human Rights (UDHR) sets out fundamental human rights to be universally protected. Although not legally binding, it remains the foundation of all international human rights law and possesses high authoritative value. Human rights standards outlined in the UDHR and other international human rights conventions, declarations, and consensus agreements require states to respect, protect, and fulfill the sexual and reproductive rights of individuals as part of their right to health. This section will outline the human rights framework that legally, politically, and morally binds states to ensure the sexual and reproductive rights of individuals.
Adopted in 1979, the Convention on the Elimination of All Forms of Discrimination against Women (CEDAW) addresses gender-based discrimination and is often considered an international bill of rights for women. It is the only human rights treaty that affirms the sexual and reproductive rights of women as a fundamental aspect of their right to health. Article 10 guarantees women equal rights in access to education, which includes information and advice on family planning. Article 16 guarantees women equality in matters relating to marriage and family relations, which includes the right to decide on the number and spacing of their children. CEDAW requires states to eliminate discrimination against women and girls in the health sector, challenge traditional norms that perpetuate the notion that men are superior to women, ensure that men and women have an equal say in the number, timing, and spacing of the children they have, guarantee access to information to enable family planning, and prevent violence against women and girls. In 1999, the CEDAW committee, which monitors the implementation of the convention, issued a recommendation that invited states to prioritize the use of family planning and sex education to prevent unwanted pregnancies. Only six United Nations member states have not ratified the convention: Iran, Palau, Somalia, Sudan, Tonga, and the United States.
In 1994, the International Conference on Population and Development (ICPD) in Cairo concluded with the creation of a guide to people-centered development progress. Prior to the Conference, the focus had been on population control through fertility control. The ICPD Programme of Action represented a step towards the recognition of sexual and reproductive health as a human right, as well as the recognition of the empowerment of women and gender equality as fundamental to population and development programs. Although it is not legally binding, the legal instrument possesses authoritative value due to its endorsement by 179 states.
The program urges states to make reproductive health accessible through the primary healthcare system, which includes “family planning counselling, information, education, communication and services; education and services for prenatal care, safe delivery and post-natal care, especially breastfeeding and infant and women’s health care; prevention and treatment of infertility; abortion as specified in paragraph 8.25; treatment of reproductive tract infections, sexually transmitted diseases (STDs) and other reproductive health conditions; and information, education and counselling on human sexuality, reproductive health and responsible parenthood.”
In 1995, the Beijing Declaration and Platform for Action was adopted during the Fourth World Conference on Women (FWCW). The Declaration represented a historic pledge by governments to protect the human rights of women, along with their sexual and reproductive rights. It states that the right to decide on matters related to sexual and reproductive health is considered a human right of women. Some of the topics covered in the Declaration include: abortion, family planning, female genital mutilation, HIV/AIDS, marriage and family law, rape and sexual violence, and safe pregnancy.
The African Charter on Human and Peoples’ Rights (Banjul Charter), which was drafted in 1981 and entered into force in 1986, was created to promote and protect human rights in Africa. The Charter guarantees the right of women to decide on the number and spacing of her children, the right to access to information and education about family planning, and the right to access methods and services related to family planning.
In 2003, the African Union adopted the Protocol to the African Charter on Human and Peoples’ Rights on the Rights of Women in Africa (Maputo Protocol), which guarantees the right to political participation, the right to socio political equality between men and women, the right to autonomy in their reproductive health decisions, and the end to female genital mutilation. The Protocol was ratified by 15 out of the 55 member states of the African Union. Article 23 guarantees the right of women to control their fertility and use family planning services. Article 25 guarantees the right to reproductive choice and autonomy. Finally, article 14 guarantees the right of women to have a medical abortion in cases of “sexual assault, rape, incest, and where the continued pregnancy endangers the mental and physical health of the mother or the life of the mother or the foetus.”
Somalia is a country located in the Horn of Africa bordering Djibouti, Ethiopia and Kenya. Formed in 1960 by the federation of a former Italian colony and a British protectorate, the country was led by Dictator Mohamed Siad Barre from 1969. He lost power in 1991 when his dictatorship was overthrown in a civil war sparked by clan-based guerrillas. That same year, the independent Republic of Somaliland was declared in the north of the country by the de facto government.
The reasons leading to such separation can be traced back to colonial rule. Around the 19th century, the Somali peninsula became of interest to various powers. On one hand, France, Great Britain and Italy wanted to gain control over the territory where they had recently opened coaling stations. On the other hand, Egypt and Ethiopia wanted to exercise influence in the region. While Egypt gained power over Bullaxaar (Bulhar) and Berbera in the north of the country. However, due to the disorganization caused by the revolts happening in Sudan during that period, Egypt had to put an end to its colonial efforts in Somalia. This forced the British to fill such a vacuum and, between 1884 and 1886, drafted up treaties of protection guaranteeing main northern Somali clans their independence. While the territory was not given fully to the British colonizers, a protectorate was proclaimed. Furthermore, in order to avoid a clash with the expanding French colony, an Anglo-French agreement on the boundaries of their Somali possessions was signed in 1888. Around the same time, Italy expanded its colony in Eritrea and started to expand their power towards Ethiopia. The following year Italy established its protectorate over Ethiopia and acquired two protectorates in the northeastern corner of Somalia. Furthermore, by the end of 1889 Italy was sublet the southern part of the Somali coast. In 1905, Italy eventually gained direct responsibility over its possessions in Somalia, which turned into the colony of Italian Somaliland.
During the Second World War, Italy conquered British Somalia in 1940 for a short period. After that, Somalia, except for French Somaliland, remained under British rule for another decade. This was until 1949, when Somalia was put under a 10-year long UN mandated Italian Trusteeship by a United Nations Assembly decision. British Somaliland (Somaliland) achieved independence in 1960, following the struggle of pan-Somalism movements aiming at uniting the five Somali territories under one state. Italian Somaliland (Somalia) became independent a few days later.
Soon after regaining their independence, the two territories eventually decided to unite in order to create a “Greater Somalia” and bring together all people of ethnic Somali origin in the Horn of Africa. However, the creation of a unified country soon turned out to be disadvantageous for Somaliland. First, they were practically excluded from the drafting of the union act for the newly established Republic. As the national assembly tasked with writing such act was formed by 33 MPs from Somaliland and 90 MPs from Somalia, all the 23 Articles proposed by the parliament of Somaliland were ignored. The final draft contained two Articles concerning the amalgamation of the two governments and the merging of the two parliaments. Second, Somaliland was given little to no recognition in the newly formed government. Mogarishu, the capital of former Italian Somaliland, was chosen as the new capital of the Somali Republic. Representatives from the south of the country (Somalia) took all crucial positions such as the President, the Prime Minister, army commanders and key cabinet positions. In the new government led by Prime Minister Abdirashid Ali Sharmarke, representatives from the north (Somaliland) were granted only four ministerial positions out of the 14 available. The dissatisfaction and disappointment of the people of Somaliland culminated in 1961, when the Somali National Leagues (SNL), the most powerful party from the north, boycotted the referendum on the approval of the new Constitution. The majority of the population in Somaliland rejected it as well. A few months later, a group of military officials from Somaliland attempted to overthrow the government but failed. Following a successful military coup in 1969 following the assassination of President Abdirashid Ali Sharmarke, the longtime serving military leader of Somalia Mohamed Siad Barre gained power. By favoring the Darod’s, his clan, the President actively oppressed the Isaaq, clan to which the majority of the population belonged. Such discrimination led to the formation of the Somali National Movement (SNM), an opposition group particularly popular in the north of the country. The ethnic tensions in the country reached breaking point in 1988, when a civil war broke out and divided the population in pro and anti Barre fractions. During this time, crimes against humanities and atrocities were committed in Somaliland. This resulted in the killings of an estimated 50.000 civilians and in the displacement of an estimated 500.000 people. Northern towns such as Hargeisa and Burao were shelled and bombed. Government forces also laid over a million unmarked land mines in the north.
The conflict eventually brought an end to Barre’s dictatorship in 1991. That same year Somaliland declared its independence, declared its withdrawal from the 1960 Act of Union and entrusted leading SNM members with the formation of a new government. However, a peaceful transition was only reached in 1993, following another clan conference in the city of Borama. Here clan elders and representatives of other key groups adopted a peace and a national charter and Mohamed Haji Ibrahim Egal was elected as new President.
Nowadays, the overwhelming majority of individuals in the center and west of Somaliland support the independence of the country. The political stability enjoyed by these areas have allowed them to develop significantly under various aspects and to engage with international organizations. However, the eastern parts of the country remain in conflict as Somaliland exercises limited control over the area. Furthermore, the country suffers from the lack of recognition of the majority of states, which support the unity of the country with Somalia due to economic interests. While Somalia and Somaliland have engaged in some negotiations, they have led to no significant results, as the two countries remain set on their positions.
Reproductive Health in Somaliland
Sexual and Gender-Based Violence – SGBV
As a cultural and social phenomenon, SGBV has an enormous impact and is directly linked to female health. In Somaliland, this is a key and widespread threat to women and girls and takes place in a normalized and unpunished way through practices such as: intimate partner violence (or domestic violence), rape, female genital mutilation, trafficking for forced labor and sexual exploitation, child marriage, forced marriage, and denial of resources. Also, general discrimination can also be considered a form of gender-based violence because of its many consequences, like the biased and negligent assistance of women that appeal to the justice system in cases of physical aggression and sexual assault.
The stigmas, conservative social norms and religious beliefs have prevailed in Somaliland, sustained by a clan-based legal system that is composed of state actors, clan alders and religious leaders. This leads to a conducive and propitious atmosphere for violence with high rates of silencing and blame toward rape victims, who are ostracized within their own communities based on the idea of impurity. Many rape crimes are resolved through marriage, financial compensation, negotiation between families out of the court, and hardly there is a specialized health treatment service or psychological support for survivors –if they ever report it to the police. Out of fear of stigma and retaliation, women and girls hardly open up and reach for support whether from their community or their judicial system.
Health services that provide a clinical management of rape are far from meeting good standards of care, not only by virtue of lack of drugs and equipment for a situation of sexual assault, but also lack of appropriate trained personnel, which is a further risk for the victim. Since hospitals and health centers are majorly concentrated in large cities and towns, there is a greater vulnerability and higher exposure to GBV in places like internally displaced people camps, host communities and hard-to-reach locations. These are characterized by restricted access to services, schools, lack of separated sanitary facilities, lack of private spaces in health facilities to examine and counsel women, among other factors. Notable, this kind of conditions are also harmful to Somaliland’s women and girls that are pregnant or in reproductive age.
One of the major problems in Somaliland is domestic violence, in the sense of physical aggression by an intimate partner, a hard practice to quantitatively assess because of high acceptance among both men and women. Consequently, it goes largely unreported. A study published by the Gender Index, in 2019, showed that 76% of the female population justifies domestic violence. Nonetheless, the most common, extremely widespread, and accepted practice of gender-based violence in the country is, indisputably, female genital mutilation.
Perceived as normal in Somaliland, socially accepted as a protection of the child and a requirement for marriage, female genital mutilation occurs between the ages of 4 and 14. There is a prevalence of 99% in women and girls of 15 to 49 – the highest percentage in the world. Being mutilated has a large effect on the health and daily life of women and girls, since it causes swelling, infections, and great deals of pain in the time recently after, and to urinate and menstruate. During period, the menstrual flow is restricted due to the mutilation and the bleeding is prolonged.
Despite the resistance of FGM in the face of international and global efforts to end it in all its forms, there has been a notable shift in the practice. First, in January 2018 a study by the Population Council indicated an increase of medicalized FGMs, that is, the performance by nurses and midwives in healthcare facilities or private homes. Furthermore, the study noticed that the most severe and aggressive type of mutilation (and the most common in Somaliland), Infibulation or Pharaonic Circumcision, has been less executed, alongside a higher occurrence of alternative types called sunna, which many believe to be sanctioned by Islam. However, there is only qualitative data and descriptive report on this matter, without official and reliable data on FGM in Somaliland and the prevalence of its types. The government has not conducted quantitative research to discover accurate information, and the continuance of conflicts and instabilities in the country has hindered international or non-governmental organizations to search for this data.
It is important to know that FGM does not passes unnoticed or is completely normalized in Somaliland. There are a lot of international initiatives in partnership with society groups and governmental agencies to tackle the problem and promote change regarding genital mutilation. The Network against Female Genital Mutilation in Somaliland (NAFIS) exists since 2006, composed of 20 civil society organizations that operates in all locations of the country. So far, to support women and girls who survived FMG and suffer complications, it has created 3 support centers, 21 mother and child health centers and 3 general hospitals. In addition, since May 2021, the European Union and the Somaliland Ministry of Employment, Social Affairs and Family established two projects to fight not only the practice of mutilation, but the over all sexual and gender-based violence. The initiatives are named “Accelerating Change to Abandon Sexual Gender Based Violence and Female Genital Mutilation” and “Somaliland Termination Oppression of women and girls Programme II” (STOP II).
The legal system of Somaliland works as a combination of civil law, a customary law called Xeer and Sharia (Islamic) law. The latter, which can be detrimental to women and girls in some respects, detains primacy above all laws, and Xeer also has great influence, turning formal law into the less strong instrument of the system. The Constitution of Somaliland, approved in 2001, addresses specifically women’s rights and duties only when referring to the Sharia law. There is no law to particularly protect women from violence, only general provisions regarding the security of any person and the prohibition of “physical punishment and any other injury”.
The Constitution confirmed in Article 10 compliance with all international agreements previously signed and ratified by Somalia, and declared in Article 130:
‘’All the laws of the Federal Republic of Somalia which were current and which did not conflict with the Islamic Sharia, individual rights and fundamental freedoms shall remain in force in the country of the Republic of Somaliland until the promulgation of laws which are in accord with the Constitution of the Republic of Somaliland.’’
Therefore, this shall include in Somaliland’s domestic regulations the Penal Code of Somalia, from 1962, which criminalizes sexual violence and describes the conditions of these crimes. It also prohibits abortion in a very restrictive way, with the only exception of saving the life of the woman. In addition, to cause hurt to someone occasioning in physical or mental illness becomes a criminal offense, and the punishment is greater if the hurt is deemed “very grievous”, when, among other, it results in “(c) loss of a limb, or a mutilation which renders the limb useless, or the loss of the use of an organ or of the capacity to procreate”.
Regarding international documents, Somalia has not ratified the Maputo Protocol, nor signed or ratified the Universal Declaration of Human Rights, creating a worrying issue when it comes to women protection and security. However, the 2001 document states that Somaliland recognizes and shall act in conformity with the United Nations Charter and the Universal Declaration of Human Rights. It even mentions the prohibition of “crimes against human rights” such as “torture” and “mutilation”.
With these provisions in mind, although not too many, one can identify breaches to advocate against female genital mutilation, even if the Constitution or any other law/document refers specifically to this practice. Nonetheless, it is exactly the lack of mention that hampers prosecutions or arrests, because there is not a definition of what would precisely be FGM – the closer possible are the “long lasting bad practices” referred to in Article 8, that shall be a national obligation to eradicate.
Only in recent years reality has begun to change for women and girls in Somaliland. On February 06, 2018, the International Day of Zero Tolerance for Female Genital Mutilation, the Ministry of Religious Affairs issued a fatwa that banned and punished Infibulation and allowed compensation for victims. This declaration from the government in the form of a fatwa has deep significance since it becomes part of the country’s Sharia law and informs that FGM has no religious or cultural basis. Notably, this was only a month after the publication of the study conducted by the Population Council, mentioned in the previous section.
The action of the Ministry of Religious Affairs created an expectation for a bill against FGM, a formal law instrument, to come before the parliament – in part because of the moment Somaliland’s law was living regarding sexual offences. In January 2018, the Rape and Sexual Offences Act (Law No. 78/2018) was approved by the country’s parliament and signed by the president 7 months later, criminalizing and strongly standing against rape. The aim was to define and explicitly prohibit all forms of sexual violence, including gang rape (never mentioned in the 1962 Penal Code), child marriage, trafficking, among others. Referring to gang rape was a very important point in this law, because it recognized the horrifying increase of reported cases in the last few years, setting sentences for rapists of at least 20 years in prison.
Law no. 78/2018 had provision to strengthen the mechanisms available for the victims of violence, such as health services, psychosocial support, legal aid, and economic programs to empower survivors that decided to leave their homes or husbands. Unfortunately, withing Somaliland there were strong disagreements and oppositions, which led to extensive amendments in 2019 and the suspension of the law shortly after. In August 2020, a new and revised bill (No. 78/2020) took place, the Rape, Fornication and Other Related Offences Bill, prepared without any public debate or consultation of women, lawyers and civil society in general.
It is widely considered more conservative and a set backwards for women’s rights due to a number of elements such as the allowance of child and forced marriage – a child being considered anyone below the age of 15 –, and of marriage for mentally ill people arranged by their parents or guardians. Moreover, the bill removed important definitions of the types of gender-based violence that were in the previous document, which accounted for forensic science as a mean to obtain evidence of rape. Now, the definition of rape is narrower and the idea of lack of consent is excluded, with more emphasis on coercion, and there is requirement of an eyewitness as evidence. Lastly, leniency and high possibilities of impunity are clear, since an article states that if the accused “is a good person with a good reputation withing the community, he/she will not be arrested unless proven otherwise”, and there will be punishment for false claims “to protect people known to be good and respected within the community”.
The issue of menstrual dignity is critical in Somaliland, from lack of education and knowledge regarding menstruation and the female body to the lack of resources, distance from health facilities or other places to buy pads, lack of private spaces for disposal of pads or washing reusable pads (if there is access to them), among others. Further, even when the items are available for purchase, women and girls often do not have enough money to afford. Therefore, the reality is that many people use clothes in the underwear to absorb the months flow or they bleed without any protective material. In 2016, the International Federation of Red Cross and Red Crescent Societies (IFRC) published the result of a 2-year-long study, and in Somaliland 44% of the respondents used the clothes during menstruation, and 37% did not use anything at all.
Also during periods, 40.9% bathed only once a week, 32.3% twice a week, and just 26% bathed daily. The situation is worsened in times of water scarcity, because bathing is less available and the cloth is not possible to wash before re-using, so women and girls keep it until the rainy season or bury it or burn it. All of this has a major impact in how the daily life changes during menstruation, since not using a protection or using an inadequate protection restricts movement and simple activities, such as fetching water (considered the main restriction for 24%), attending school and going to markets – 79% reported to have some restriction. Another consequence is the possibility to experience itching, irritation or smelly discharge and develop infections due to the inappropriate sanitation.
The IFRC initiative is one of the many current projects longing for change and promotion of a better life to women and girls. For two years in Somaliland (and other countries), a work aimed to better understand the menstrual hygiene management (MHM) and provide kits with items like disposable and reusable pads, underwear, bathing and laundry soap, plastic bucket, among others. The kits came with instructions and during distribution the volunteer staff made demonstrations regarding using and care and conducted discussions on pregnancy, sexually transmitted infections, and intimate hygiene.
(International Federation of Red Cross and Red Crescent Societies, 2016)
With the most common sources of MHM being mothers (35%), elder sisters/cousins (26%) and friends (12.4%), the information and demonstrations were realized to be extremely important to the knowledge of women and girls. Months after the distribution of the kits, the percentage of respondents who could correctly identify the normal duration of a period went from 84% to 94%, with a notable increase amongst adolescent. Moreover, 64% had the knowledge that not experiencing monthly period could mean pregnancy, compared to 47% before the actions.
In a very short time, great changes for the better were observed and female life definitely gained more quality, which got them closer to a situation of real menstrual dignity. The previous amount of 79% of respondents reporting restrictions during menstruation reduced to only 6%, and young girls were particularly happy because they could go to school. Besides, only 1% remained experiencing itching, irritation, and smelly discharge. However, some structural circumstances in the area continued to hinder more advances, such as the 62% of respondents who lacked money to purchase pads or lacked available places to obtain them, and many also reported lack of private facilities to dispose pads.
Three months after the actions, focused group discussions were held so women could talk about the changes in their lives, participate and express themselves. A key point was that women and girls did not report feeling embarrassed during their periods, because the fear of blood leaking out was no longer present. All of them expressed the importance of the information and demonstration sessions and the materials for education, since it made them aware of the proper use and care of each item they received and, in addition, increased knowledge on hygiene practices and health they were not previously aware that existed.
Challenges to the development of sexual and reproductive health dignity in Somaliland
When considering the points previously expressed regarding sexual and reproductive health in Somaliland, some barriers to its development and progression should be highlighted. Among the challenges concerning each topic already mentioned, here we will divide the analysis around recurring challenges to be addressed concerning state actions, social and community influence and roots, and last but not least the influence of cultural and religious stigmas on women’s health practices.
Economic and State-based challenges
From the state point of view, in the sense of infrastructure and policies of shelter and promotion of better women’s health, it is necessary to remember some data about the country. As a direct result of the great insecurity and conflicts with neighbouring communities, as well as the civil war of the 1990s, the socio-economic situation of Somaliland has deteriorated exponentially, affecting areas such as education and livelihoods. This situation is most easily seen when we consider that approximately 84,000 internally displaced persons (IDPs) live in camps in Somaliland. Another fact that corroborates directly with health insecurity in the country is the high unemployment rate that amounts to 60% of the total population, as well as the illiteracy rate that reaches 70% in several areas. In terms of infrastructure and development, as the region is not internationally recognised and is frequently involved in episodes of conflict, some donors and organisations face obstacles in promoting aid. This leaves the country extremely dependent on donations from the Somaliland diaspora, which is at the forefront of financing the country’s economy.
In terms of infrastructure, only 40.5% of households in the country have access to water and sanitation, with at least a third of households living about an hour away from their main water source. Similarly, infant mortality is very high, with one in eleven children dying before their first birthday. From this brief profile of Somaliland’s infrastructure and development we can begin to analyse how the actions (or lack thereof) of the state directly influence the sustainable development of sexual and reproductive health in Somaliland.
From a socio-economic perspective, a study conducted by the UN Population Fund found that most women in the country stated financial constraints as the main reason for not being able to access adequate healthcare. It also highlighted that the distance to health facilities was the dominant reason among nomadic women and those living in rural areas of the country. The lack of state infrastructure is also present as a major obstacle to accessing and seeking antenatal and early birth care. In general, women who are less likely to seek antenatal care services are predominantly rural and less educated. This inequality, coupled with difficulties in accessing family planning methods and the high fertility rates of women in the region, places women at high risk of mortality during pregnancy and postpartum, not surprisingly Somaliland’s maternal mortality rates are among the highest in the world
As discussed above, FGM is a constant in Somaliland culture and it also faces public policy challenges in bringing it under control. The impact of FGM on the health of women and girls is undeniable, yet health workers face multiple challenges in their prevention and case management roles at the individual level. For instance, lack of formal and specific training on prevention and medicalization of FGM related cases. At the institutional level, many facilities lack the equipment and funding to effectively manage cases and complications for women in the region.
Social and community-based Challenges
The second focus of our analysis of the sexual and reproductive health challenges in Somaliland is on social and community issues. Here we highlight the channels of information and awareness about certain issues and the prevalence of reliance on familiar and nearby sources rather than sources that are necessarily scientific or foreign. In this way we were able to analyse not only whether information reaches women and girls in urban and rural areas of the country, but essentially how this information is interpreted. Despite data expressing that 80% of the women of the country know at least one form of contraception, the majority of women (almost 73%) consider and use lactational amenorrhea (LAM) as the main method of contraception, which only exacerbates the fact that it is not enough for information to arrive, but it must also make sense for the community and social context of the women of the region.
There is also a wide divergence in access to information; despite being in the minority, urban women are more likely to access information on birth spacing and STI’s on the radio or similar sources, in contrast to 94% of rural and rural women who have never heard of a campaign in any form of media. Importantly, this second profile is the most prevalent in the regions of Somaliland that do not include the capital. It is important to highlight the community culture among Somaliland women, as when they speak out about what has happened, ninety percent of the women who suffer or have suffered physical violence seek help from their families.
However, in the same way that communities play a supportive role in cases of violence, they also form a bubble that encourages pre-judged notions about various terms of women’s health. We can see this clearly especially with regard to antenatal care and early birth care, as women in some communities tend to consider antenatal care as unnecessary.
Additionally, a collective understanding is held that there were good professionals, but most midwives in the health facilities were not sufficiently trained, causing a growing distrust of seeking these types of treatments and consultations. And this distrust would be further exacerbated by beliefs strengthened by family members of these women, that the medications provided in the antenatal clinic would cause menopause, infertility or increase stillbirth mortality. Besides the fear of the midwives’ judgment, since there would also be a collective belief that these professionals ‘did not like’ women who had many children, which goes directly against the cultural average of desired children per family, which is eight.
One of the most present challenges in women and girls’ decision to seek clinics and health care professionals when needed is women’s social positions and obligations in Somaliland homes. Here an intersection between infrastructural and social challenges is favoured, as in most homes women reported that there would be no one to leave their children with to attend visits and clinic visits, and even if there was a responsible person, the visits were presented as time consuming (due to waiting and dislocation time). In this sense, the population tends to consider this care as a waste of time and money, in addition to the fact that it would be preferable to rest at home than visit the health centres. Still on the influence of communities and family members, it is not uncommon for family members and older counsellors to discourage women from seeking health services, even when others reinforce their benefits.
Social positions also translate into the home, since in Somaliland families it is common for women to take on all domestic duties while husbands provide financially. Thus, women’s actions are extremely dependent not only on their husbands’ funding, but also on their authorization and trust in health services, which is said to be rare.
Cultural and Religious Challenges
The third perspective that makes up our analysis of the challenges to the development of dignity in women’s health is the cultural and religious perspective. As we have already mentioned, religion plays a dominant role in policy making and decision-making in Somaliland, highlighting here again the use of Sharia law in the constitution. This cultural and religious influence becomes more latent when we discuss the persistence of FGM in the country. Since the majority of Somaliland women believe that the act of cutting the genitals is a religious obligation, being done by traditional circumcisers, and yet, this same majority agrees with the continuation of the practice.
The cultural and religious obligations that govern the social norms of Somaliland communities see FGM as a necessary act for the moral development and preparation of girls for future marriage. Reaffirming an assumption that mutilation would preserve the virginity of women, who would be more likely to marry virgins and prevent promiscuity. These social norms are so ingrained that 78% of nomadic women would like the practice to continue, increasing the likelihood that girls in subsequent generations will suffer the same kind of violence. Although most health workers support the discontinuation of FGM, especially the pharaonic type because of its effects on women’s physical, mental and social well being; some health workers still support the other types of FGM – the sunna type – arguing mainly that this type of incision is recommended by Islam, and it does not pose health risks for girls and women, in fact serving as a type of purification.
Still under the cultural and religious umbrella, as mentioned before, social norms transcend the walls and directly influence decisions within the households. Although it can be considered a type of violence, the Somaliland cultural and religious context holds that to some extent women’s actions and behaviours are legitimately controlled by their husbands. Furthermore, culturally, women must consent to sexual intercourse regardless of menstruation, illness, or fasting; the ultimate goal being the happiness of marriage. Posing a final threat to not only women’s health dignity, but also their mental and physical well-being.
Having presented the main challenges facing the dignity of women’s health in Somaliland, we have seen that the three levels that guide our analysis in this section are interrelated and influence each other concomitantly, leaving policies to solve these problems with increasingly complex and comprehensive needs. Reacting to a web of cultural, religious or political measures that are rooted in Somaliland’s very sense of nationality, creating a cycle of female health insecurity that goes beyond awareness campaigns and needs local roots to grow sustainably and engage real change in the lives of Somaliland women and girls.
The Impact of COVID-19 Pandemic and Women’s Health Insecurity in Somaliland
Barriers to health services that were worsened after the start of COVID-19 or created because of COVID-19
Difficulties in accessing basic services, such as health and livelihood programs were already present in Somaliland prior to COVID-19 and its restrictions. Related COVID-19 restrictions of movement and its effects further caused an overload of work for the health centers along with greatly affecting healthcare seeking behavior of the community and posing an even greater challenge in accessing healthcare and medication. This is because the global threat forced humanitarian organizations to re-prioritize the services they were providing and to focus more of their efforts on pandemic response and preparedness, to mitigate its impact on marginalized populations in what was an already underfunded humanitarian response.
This meant women and girls had more difficulties in accessing health services due to mobility restrictions imposed on the local and global population and lack of resources. In particular, services for sexual and reproductive health (SRH) impacted the number of supplies women and girls were receiving from hospitals due to the fear of medical professionals contracting COVID-19. Many hospitals – most of them private institutions – even stopped admitting patients or working fully. The Somali health system is dominated by private hospitals and clinics with an irregular service provision, particularly in rural areas. During COVID-19, most of the rural private hospitals and clinics provided little to no mother and child health (MCH) service-delivery which resulted from the shutdown of international flights. The majority of Somaliland women and girls who were interviewed this year by the Mixed Migration Center stated that they felt they would not be able to access healthcare services if they presented COVID-19 symptoms (80%), or if they had other health concerns (79%). However, the most-frequently cited barriers to accessing health services was not knowing where to go for healthcare during the pandemic (62%) and not having money to pay for the services due to increased Doctor fees and prices (48%).
Since accessing health services and products continues to be a serious problem for women and girls in the community due to COVID-19, women and girls are forced to use make-shift products such as cloth pads. Prior to COVID-19, traditional pads were used as the common technique of dealing with monthly periods, due to the fact that many women and girls had access to pads provided as part of humanitarian aid. However, restricted air travel has made traditional pads less available and if they are, they are extremely expensive. And since most do not possess other necessary hygiene supplies, such as soap and shampoo, most women and girls report using ash and clay instead to wash the cotton cloth pads or having to wait until the rainy season.
Programs or acts implemented during COVID-19 to lessen gender inequality
Due to already existing patriarchal and cultural gender norms and now an emphasis on movement restrictions related to COVID-10 measures, women activists and women’s rights organizations (WRO) continue to be underrepresented in decision making spaces especially decisions linked to COVID-19 responses. Prior to COVID-19, WRO’s have been frontline providers of health services and products to many women and girls. However, ever since the global pandemic, many WRO’s have reported difficulties in continuing their operations as a result of aid restrictions. But, in response to the global crisis, the Ministry of Health and Human Services set up a National Preparedness and Response Plan for CoronaVirus Disease, March – August 2020 which issued directives to close schools, ban social events and gathering, and restrict flights and travel into Somaliland. The plan had 10 pillars, none of which focused on, or included, risk mitigation of the gendered impacts of the pandemic or ensured women’s and girl’s rights. Only two pillars made a reference to gender-related or women and girl-specific needs, namely lifesaving maternal and neonatal services, but only in the Psychosocial Care Pillar.
Following this Plan, the UN and partners launched a Country Preparedness and Response Plan (CRP) COVID-19 to respond to the humanitarian and socio-economic consequences of the pandemic. In contrast to previous emergency response plans, including the Ebola response, which side-lines gender, the CRP integrates gender comprehensively. It rightly points out that women and girls, together with marginalised groups, are at a greater risk of vulnerabilities caused by COVID-19.
Thanks to international involvement, issues women and girls are facing due to COVID-19 are being accounted for in Somaliland. However, the government itself should prioritize access to SRH in emergency response and preparedness plans and financial resource allocation (including those for COVID-19). This would include strengthening the health service sectors, both in systems and capacity, to ensure that women and girls from all backgrounds and groups have full access to timely and quality services and products. Measures to contain the virus (such as restricted mobility) should not affect women’s access to SRH services. It is also important for non profits and international donors to work with community groups and leaders in ensuring a good spread of information on how and where to access SHR services and products using different communication channels. Also, an investment in services and products should be maintained in order to prevent further shortages necessary to treat SHR issues. This would help to prevent and mitigate any difficulties that would result from distribution issues and ensure health centers and doctors have a sufficient supply of SRH products to continue working safely and effectively in rural and remote areas as well.
In light of the previously mentioned issues surrounding women’s reproductive health and menstrual dignity in Somaliland, the following section will focus on policy recommendations that Somaliland may implement and enforce.
The policy recommendations will focus on relevant articles of international treaties. However, we must bear in mind that Somaliland is not recognized as an independent State within the African Union or in the broader international community of States; it is recognized solely as an autonomous region within Somalia. Since it is not recognized as a state, and has no legal personality or international standing, Somaliland is not part of the UN or the African Union. Therefore, it is not a signature to and bound by international treaties or agreements set out by these organizations. The policy recommendations will however focus on implementing international customs and laws into the domestic legal system, to use as a model for the improvement of Somaliland’s policies on women’s reproductive health and menstrual dignity.
The first recommendation on policy is focused on health care workers in Somaliland, as they play a critical role in the prevention and treatment of complications with for example female genital mutilation (FGM) or other reproductive health issues. In FGM, according to health care professionals in Hargeisa, Somaliland has no policies on the management and care of the woman suffering from FGM, only treat those with severe complications. It is therefore essential that the Somaliland government implement a policy in which they receive a comprehensive training to diagnose and treat FGM-related complications or other complications related to women’s sexual and reproductive health. The strengthening and development of the capacity of health care workers to manage all sexual and reproductive health complications and prevent the medicalization of FGM within and outside the clinical settings is needed. The policy must enshrine the fact that in rural areas, with minimal resources and the most cases of FGM and other reproductive health issues, special attention must be paid to the training of health workers. The policy must enshrine clinical guidelines, as well as guidelines on the of health facilities in order to manage complications surrounding the practice of FGM and complications in other sexual and reproductive health issues.
The second policy recommendation the Somaliland government is advised to implement is the Menstrual Hygiene Management (MHM). This is a set of operational guidelines to eliminate challenges that young girls come across with the management of menstruation, by implementing a range of actions and interventions. These challenges include inadequate water and sanitation facilities at school, limited access to effective, hygienic materials for menstrual management and inaccurate information about menstruation and the biology of puberty, cultural taboos and restrictions which can impact access to services and daily life, anxiety, and embarrassment around leakage of blood, and discomfort associated with menstruation. If menstrual hygiene is not appropriately addressed, persons who menstruate may face irritation or infections, the risk of sexual and gender-based violence, restricted movement, and inability to attend distributions or access services. MHM includes comprehensive education and health approaches, programming that ensures the access to services, a safe and enabling learning environment, skills-based learning and community and policy support. It contains three essential components for an effective MHM response, including access to MHM materials and supportive items; private, safe, and appropriate sanitary facilities; and information. This policy is in line with art. 15(1) of the Somaliland Constitution, which states that the state shall advance, extend, disseminate knowledge and education as it recognizes that education is the most appropriate investment that can play a major role in political, economic, and social development.
Next to this, it is crucial for the government of Somaliland to provide and implement a coherent legislative framework on reproductive health and menstrual issues and challenges. Regardless of their legal status before the African Union and the UN, there are treaties such as the CEDAW, the African Charter on Human and People’s Rights (including the Maputo Protocol), which Somaliland can implement (partly) into their own legal system. Article 36 of the Somaliland Constitution sets out the rights of women, which are governed under the Sharia law. Therefore, men and women are laid down to be equal, only for matters which are specifically ordained in Islamic Sharia. Although a start to a legislative framework, it is not sufficient to address the issues of women in society related to sexual and reproductive health, and menstrual dignity. An example for a coherent legislative law is set out by article 14 of the Protocol to the African Charter on Human and People’s Rights on the rights of Women in Africa (Maputo Protocol). This article enshrines that states shall ensure the right to health of woman, including sexual and reproductive health is respected and promoted, including the rights to; control their fertility; decide whether to have children and how many; choose any method of contraception; self-protection and to be protected against sexually transmitted infections, including HIV and AIDS; to be informed of one’s health status, particularly if infected with sexually transmitted infections; and the right to family planning education.
In the General Comments on art. 14(2) of the ACHPR Maputo Protocol, it states that States must also provide adequate, affordable, and accessible health services, including information, education, and communication programs to women, especially those in rural areas. Also, states must establish and strengthen existing pre-natal, delivery and post-natal health and nutritional services for women during pregnancy and while they are breast-feeding and protect the reproductive rights of women by authorizing medical abortion in cases of sexual assault, incest, and where continued pregnancy endangers the mental and physical health of the mother or the life of the mother or the fetus. Somaliland must adhere to the international and African standards the ACHR sets out, and must implement the Maputo Protocol, particularly art. 14, into their own legal system. Next to the implementation of already existing international obligations, Somaliland must also ensure that the laws and policies prohibit discrimination in the provision of reproductive health services, including repealing laws that criminalize services solely for females and taking into consideration the specific needs of marginalized populations.
Somaliland must implement a policy where guarantees of the right to full and accurate information on sexual and reproductive health and rights, including formal sexuality education, are enshrined. It is crucial in the developmental stages of juveniles, both male and female, that adequate education and information on sexual and reproductive health, including family planning, menstruating, sexual transmittable infections, and contraception is provided. Not only to combat societal and cultural stigmas surrounding these topics, but also to decrease embarrassment, anxiety, and lack of knowledge about their own health, specifically with women and girls.
Somaliland must ensure adequate budgetary allocations for the implementation of laws and policies on sexual and reproductive health, and ensure participation of key stakeholders in the formulation, implementation and monitoring of laws, including government bodies, ministers, civil society, NGOs, and the marginalized groups impacted. The monitoring of these policies includes the tracking of and collecting of data, in order to keep track of cases of sexual and reproductive health complications to examine compliance with policies.