This document is prepared with the generous support of the sexual and reproductive health right project of FIGO to whom the society is very much grateful.

This document has passed through a number of processes to reach the present stage. A draft document, prepared by the project coordinator, has been made available for comment by the executive committee, followed by copies for the general assembly of ESOG. It then went through three review process before it has attained this form.

The executive committee of ESOG extends its appreciation to the project coordinator Dr Yirgu G/Hiwot for coordinating this activity and developing this document together with a number of individuals and organizations who have made valuable contribution to help the document achieve this form. Their name is listed in the last page. Our gratitude goes also to all teaching institutions namely departments of obstetrics and gynecology of AAU medical faculty, Jimma University, Gondar University College, Alemaya university and Dilla college of health sciences, the centralized school of nursing and school of midwifery for their contributions.

The Executive Committee of ESOG

"On behalf of the FIGO committee on Women's Sexual and Reproductive Rights, I would like to offer congratulations and my deepest gratitude for the commitment of the Ethiopian Society of Obstetricians and Gynecologists in formulating this code of Human Rights Based Ethics for reproductive health workers. I hope that it will serve as a stimulus to active discussion about how the health of women is integrally related to their human rights and the responsibilities of obstetricians and gynecologists and other reproductive health workers to advocate for Better health for women.

In Ethiopia, the maternal mortality rates are high, as in many other African countries. You deserve great credit for addressing this problem knowing that in many cases, this loss of women's lives can be prevented. In addition, your focus on violence and sexual violence will lead to improved lives and health for women, recognizing that progress can only be made by the leadership and collaboration you have demonstrated."

Kind regards,

Dorothy

Dorothy Shaw, MBChB, FRCSC

Clinical Professor

Department of Obstetrics and Gynecology and Medical Genetics

UBC

Ethiopia is one of the countries with the lowest sexual & Reproductive Health status. The maternal mortality rate 871/100,000, according 2000 DHS survey, is largely caused by avoidable causes like unsafe abortion, and obstructed labor. A CPR rate of 6 % for all modern methods and restrictive abortion law has naturally led to high rate of unwanted and unplanned pregnancy and resort to unsafe abortion. HIV/AIDS has been recognized now as a national problem not only threatening the health of the people but also the development of the nation.

This situation is not only aggravated by lack of access to services but also lack of quality sexual & reproductive health information by medical practitioners and other professionals. A number of studies by WHO and Common Wealth Medical Association have shown that providers are critical and judgmental towards adolescents.

Confidentiality is not maintained. Although Obstetrics and Gynecologic Departments instruct students on correct examination technique and correct procedures, still there is a lack in competence to carry out procedures empathetically, painlessly and with minimum discomfort.

Women’s rights are human rights and hence, the inherent and inalienable rights of all human beings, that need to be recognized and enforced. Most of these rights are enshrined in international instruments and the states party to such instruments, are both legally and morally obliged to respect them.

The proclamation of Teheran is the first international instrument in which family planning is specifically incorporated as a basic human right. It also affirms the right to freedom of choice in family planning with the restriction that it should be practiced responsibly. The World Population Plan of Action recognized in 1974 the basic right of couples and individuals to determine freely and responsibly the number and spacing of their children and to have information, education and the means to do so (Para 14 (f)).

The Convention on the Elimination of All Forms of Discrimination against Women (CEDAW) is particularly important as it directly addresses the issue of women’s rights in decisions on family size and in making use of health care services in relation to family planning. To exercise these rights appropriate measures may include creating awareness, economic capability and availability of services for women. Aside from equality of treatment between the sexes, special treatment of mothers is also called for by the Convention.

The Vienna Declaration and Program of Action in 1993 arising from the World Conference on Human Rights reaffirm that women’s rights are human rights and should be among the top concerns of UN programs and strategies. Although, not legally binding, it assists in the development of customary international law around this point.

The Cairo Declaration and Program of Action following the 1994 International Conference on Population and Development (ICPD) Provides the most extensive and comprehensive treatment of reproductive human rights. Paragraph 7(6) of the program of action outlines the scope of reproductive health rights in an exhaustive manner and obligates states to the progressive fulfillment of such rights by the year 2015. Actions that should be taken by governments in this context include designing programs which will meet the needs of women , men and adolescents; promoting community participation; putting prevention and treatment of STDs and other reproductive tract infections among reproductive health care programs; removing barriers to affordability, adequacy and quality of services; and securing conformity to human rights and to ethical and professional standards in the delivery of family planning and related reproductive health services.

The Beijing Platform For Action (1995) adopted at the Fourth World Conference on Women was a major step forward for women’s rights. It encapsulates states commitments to women’s issues including reproductive health and rights. The Beijing Platform for Action clearly recognizes that "the human rights of women included their right to have control over and decide freely and responsibly on matters related to their sexuality, including sexual and reproductive health, free of coercion, discrimination and violence." It also addresses other areas affecting reproductive health and rights such as HIV/AIDS and other sexually transmitted diseases; gender based violence ; inequality of access to health care services between men and women; and harmful traditional, customary and modern practices. These issues are central to women’s rights to reproductive and sexual health.

In this respect, the required governmental actions include reaffirming the right of women and girls to the enjoyment of the highest attainable standards of physical and mental health and thus reproductive health, through national legislation (Para. 106) (b) ) and providing more accessible, available and affordable service for sexual and reproductive health care (Para. 106 (e)). The full exercise of such rights needs to be guaranteed by governments through their national legislation and policies. Moreover, states should commit themselves to a progressive fulfillment of the provision of adequate, affordable and accessible services for reproductive health, including family planning.

The Federal Democratic Republic of Ethiopia (FDRE) in its constitution extensively addressed right of individuals in the various articles of the constitutions. Article 10 declares that human rights and freedoms emanating form the nature of mankind are inviolable and inalienable. The constitutions further states that all international agreements signed by the Ethiopia are integral part of the law of the land. These broad principles are further endorsed by other explicit articles on fundamental rights and freedoms (Chapter 3, article 14 -18) stating the right to life, security of person and liberty and prohibition against inhuman treatment. Other articles are article 24 on the right to honor and reputation, article 25 the right to equality, article 26 the right to privacy. The most shining examples of the constitution that attests to reproductive rights are article 34 which empowers citizens with equal right on entering into and during marriage at marriageable age as defined by law and the right of women in article 35 which states that "Women shall have equal rights with men. Laws, Customs and practices that oppress or cause bodily or mental harm to women are prohibited. To prevent harm arising from pregnancy and childbirth and in order to safe guard their health, women have the right of access to family planning, education, information and capacity."

These constitutional rights are further protected by the law of land which is being currently streamlined in accordance with the principles set by the constitution. The family law protects the interest of both partners, the penal law harshly penalizes perpetrator of physical and Sexual violence. Performing such practices as female genital cutting is now punishable. The national health policy also clearly identifies women and children as vulnerable groups and every effort would be made to alleviate their problem. Article 10 states in clear terms the commitment of the government to improve family health services. In addition the population policy and women policy are geared towards improving the abysmal state of reproductive health rights in the country. All the above facts underscore the commitment of the international society, and the government of Ethiopia to improve the lives of women to the betterment of families, societies, countries and the world at large.

Client provider interaction is a complex and dynamic process. Each have there own distinct expectation. A provider may want to show his/her technical competence, want to complete a procedure in the shortest time possible whereas the client may want information, treatment with dignity, human treatment. Bridging this gap between these two different expectations needs guidelines to govern the relationship between the client and the providers. Therefore the need for this document.

This code of ethics is believed to be useful to all health workers involved in reproductive health in Ethiopia. The following categories of health workers have been included as reproductive health workers namely obstetricians and gynecologists, general practitioners, health officers, mid wife nurse and nurses. it is also the society's belief that any health worker which deals with women although not principally involved in reproductive health related work may also find this guild to be useful.

The majority of health promotive and preventive activities in reproductive health like information, education and communication, family planning, screening for or preventing complications are shared responsibilities whereas difference is noted in managing complications. As result a number of cross cutting issues have been put in this document. In the process of preparation of this document it has been a consensus among participants that the provider can not function as expected without having adequate supplies and infrastructure, proper information and training for career development, and facilitative supervision and management. Particularly concern is still expressed around protection against HIV/AIDS in work places. It is the belief of the society that all concerned bodies running health institutions appreciate this problem and respond to it.

The frame work for reproductive and sexual rights include eleven internationally recognized human rights enshrined in treaties as well as the ICPD program of action, the Beijing plat form of action and other consensus documents.

1. The right to life, liberty and security

2. The right to health, reproductive health and family planning

3. The right to decide the number and spacing of ones children

4. The right to consent to marriage and to equality in marriage

5. The right to Privacy

6. The right to be free from discrimination

7. The right to modify traditions and customs that violet the right of women

8. The right not to be subjected to torture or other cruel form of human treatment

9. The right to be free from sexual violence

10. The right to information and education and

11. The right to enjoy scientific progress and to consent to experimentation

Based on discussion and feed back from the fist document and in light of the reproductive health scenario in the country, the document outlines the role of the reproductive health provider in respecting, promoting and advocating the above listed reproductive health rights.

Cognizant of the fact that citizen has an inviolable constitutional right to life, the security of person and liberty, Cognizant of the fact that respect to human dignity, reputation and honor and Considering that interference with personal freedom is punishable by law Health providers should:

1. Providers respect, promote and advocate the right of a woman to life, liberty and security.

2. Provider advocate for elimination of all forms of discrimination against women in all matters health, marriage, family relation that endanger the life of a woman.

3. Providers should individually and collectively advocate that a woman’s life should not be endangered because of pregnancy, childbirth and puerperium.

4. At all times treats his/her clients or patients with dignity and respect.

Understanding that the prevailing high maternal mortality is not only a result of lack of access to services or poor quality of services but is also a reflection of the value society places on its women

Realizing that unsafe abortion, a leading cause of maternal mortality in the country, is not only a medical problem but also a complex social-cultural problem and the consequence of a restrictive law

Realizing that HIV/AIDS is not only an important reproductive heath problem but that threatens the development of the nation.

The provider shall:

1. Make available safe, effective and affordable reproductive health services. The provider will update continuously his knowledge and skill to enable him/her discharge this responsibility to the best of his/her capacity

2. Ensure the right of clients /patients to access reproductive heath care /services without discrimination based on sex, age, ethnicity, political affiliation. Nor shall withheld any services for economic reason

3. Spearhead and collaborate in all efforts to reduce the high maternal mortality by respecting client’s right, providing quality care and advocating the improvement in status of women.

4. Teach communities about the danger of unsafe abortion, advocate for all meanness to reduce unwanted and unplanned pregnancy and hence the resort to unsafe abortion.

5. Provide care to PLWHA with out stigmatization and discrimination and shall engage in advocating and teaching abstaining from premarital sex and maintaining a monogamous relationship. The provider shall adopt standard precaution and clean and safe working environment.

6. Not object to provision of emergency (life saving) procedures. When a provider has a Conscientious objection to medical procedure or any intervention, S/He is obliged to refer the patient or client to a facility where the service can be provided.

The total fertility rate of 5.9 children/woman is high when compared to the objective of the population policy of 4 children/woman. DHS 2000 shows that more than a third of Ethiopian women have unmet need for family planning. In addition, in nearly 10% of women the decision to use contraception comes from the husband/partner.

To bring a change in this regard the provider shall:

1. respect and advocate the right of an individual to access to family planning methods. The provider shall respect and advocate the right of a woman to decide whether or not to have a child and to limit or space births.

2. respect and promote shared decision making by couples on utilizing family planning methods but ultimately respect the decision of the woman as the most important decision on whether or not to use a family planning methods.

3. organize user friendly clinics Recognizing the reproductive health needs of the Adolescents, the. Under no circumstances shall the provider discriminate or stigmatize an adolescent for requesting services.

Knowing that constitution affirms the right to marry and found a family, only with free and full consent of the partners

Realizing in certain communities of Ethiopia arranged marriage before the couples are psychologically and emotionally mature is not uncommon, that 14.4% of Ethiopian women were married at or below 15 years, and that husbands of 13.6% of married women have one or more other women as wives (DHS 2000).

Health care providers shall:

1. advocate that marriage should be consensual. All marriage should be registered legally. The age for marriage stated by the law should be applicable. Health workers should collaborate with law enforcement agencies to report underage marriage.

2. recognizes that Child and forced marriage is a basic violation of the reproductive heath right of individuals. Provider should stand against child and forced marriage. They should teach communities the harm that may arise as result of child and forced marriage. Providers should treat the physical and psychological harms that emanate from such an act and collaborate with law enforcing bodies in minimizing such acts

3. teach community members the social, psychological harm and the health effects of polygamy

Cognizant of the fact that every one has a constitutional right to privacy and realizing the personal and intimate nature of the information that the patient or client discloses, the provider shall never disclose the cause of his patient’s condition to anyone else without the consent of the patient unless ordered to do so in a court of law.

Confidentiality may not be maintained under the following condition

1. Confidentiality of information shall not be maintained if the condition of the patient falls under a notifiable disease category, or if its is a public health danger

2. Consultation for the sake of patients or clients wellbeing doesn't involve breach of confidentiality.

Understanding that all persons are equal before the law and are entitled without any discrimination to equal protection and cognizant of the constitutional right of women to enjoy equal right with men

Realizing the very low status of women and patriarchal organization of our society

The provider shall:

1. actively teach, advocate the equality between men and women. Providers in group or as an individual should denounce all forms of gender based discrimination and violence

2. not withhold an intervention or do endanger the health and life of his patient client because of race, ethnicity, religious affiliation, political outlook , social attachment or economic gain etc

3. at all times take in to consideration the special needs of the socially disadvantaged: children, adolescents and women

Whereas the constitution enforces the right of women to eliminate the influence of harmful customs and prohibit laws customs and practices that oppress or cause bodily or mental harm and the penal law prescribes punishment for those involved in activities like Female Genital Cutting

Recognizing that a variety of harmful traditional practices are conducted on children and adolescents that have an adverse effect in their future life , recognizing also a number customs and cultures that endanger the life of the of the women during pregnancy, delivery and puerperium,

The provider shall:

1. Take the lead to identify , document harmful traditional practices in the community

2. Advocate to protect the lives of women against harmful traditional practices and educate the public

Whereas the constitution protect every one form cruel, inhuman or degrading form of treatment and bodily harm and no one shall be required to perform forced or compulsory labor

It is a common practice to arrange marriage for children, take sexual advantage and exploit children and adolescents. Thousands of women are taken out of the country for modern day slavery and some lose their lives in so doing. In order to mitigate this,

1. providers as an individual and collectively respect, promote and advocate the right ofindividuals not to be subjected to any form of exploitation, sexual abuse, prostitution,human trafficking, torture. Particularly protect children from sexual exploitation and pornography.

2. considering the danger commercial sex workers face in relation to STIs and HIV/AIDS , provider should make information ,education and services available to decrease the transmission STI/HIV/AIDS

Whereas every person has an inviolable constitutional right to life, the security of person and liberty, human dignity, reputation and honor and considering that interference with personal freedom is punishable by law.

As the penal law clearly punishes those who perpetrate sexual violence, pry on children fewer than 18 or exercise deviant sexual inclination

Considering the risk to physical, mental and psychological health to the victim and the breach to sexual and reproductive health right and human right of the victim

Health providers should:

The provider shall:

1. Treat the physical and psychological results of the violence.

2. Affirm to their patients that violent acts to wards them are not acceptable.

3. Advocate for social infrastructures to provide women the choice of seeking secure refuge and ongoing counseling.

4. Affirm women’s right to be free of physical and psychological violence, particularly sexual violence, sexual intercourse without consent within marriage.

5. Advocate for non-violent resolutions in relationships by enlisting the aid of social workers and other health care workers where appropriate.

6. Make themselves and others aware of the harmful effects of the embedded discrimination against women in social system

It is an inalienable bill of right of a client or patient to access service, to information ,to informed choice and informed consent . it is also a constitutional right of women to access in formation to avoid the harm arising from pregnancy and child birth and safe guard their health

The provider shall has an obligation to

1. provide a patient or a client under his/her care information on diagnosis, treatment, follows up care and outcome of condition.

2. clearly explain the benefits and risks ( health , financial ,social) of the alternative care options, Where alternative of management is available

3. engage himself /herself in educating the public on matter of sexual and reproductive health

1. Providers are obliged to continuously update their knowledge and skill to provide acceptable and current treatment. Providers are obliged to use technologies and medications that are effective, safe, and affordable.

2. Providers should respect and promote the interest of their patients and clients, provide full information on the benefits and risks of getting involved in experimentation and under no circumstance induce or withhold benefit to coerce individuals to be research subjects

Ethiopian Federal Democratic Republic , The Constitution of the Federal Democratic Republic of Ethiopia , Federal Negarit Gazeta, 1,1995

Ministry of health, Addis Ababa, Medical ethics for physicians practicing in Ethiopia December, 1987

International federation of obstetrics and gynecology (FIGO), recommendation on ethical issues in obstetrics and gynecology, FIGO committee for the ethical aspect of human reproduction and women's health, August 2000

Bringing right to bear, an analysis of the work of UN treaty monitoring bodies on reproductive and sexual rights, university of Toronto 2002

Health a complete physical , mental and social well being not merely an absence of disease or infirmity

Gender based violence physical, mental or social abuse (including sexual violence) including acts, attempted or threatened, done with some type of force, manipulation, or coercion and without the informed consent of the affected person/survivor

Reproductive health a complete physical mental and social well-being in all matters related to reproduction its functions and processes

Torture an intentional act inflicted for reasons based on discrimination of any kind, which causes sever physical or mental suffering and is committed with the consent or acquiescence of a public official

Dr. Feiruz surur president

Dr. Abdulhamid Isehake hon. Secretary

Dr. Adanech Belay Treasurer

Dr. Zufan Lakew Member

Dr. Neway Tekle Member

Dr. Biruk Taffesse Member

Dr. Hailegiorgis Ayteenfisu Member

Project coordinator: Dr. Yirgu G/hiwot

1. Dr. Dehab Belay Head National Committee on elimination of harmful traditional practices

2. Wo. Ellen Alem Lawyer, Ethiopian Women Lawyers Association

3. Ato. Amare Bedada CEO, Family guidance association of Ethiopia

4. Dr. Solomon Kumbi Project coordinator ,SMP, ESOG

5. S/r Tsigereda Tiruneh Representative, Midwifery School

6. Dr. Tewodros G/Michael Representative, Engender Health

7. S/r Kiros Kebede President, Midwives Association

8. S/r Yegomawork Gossaye President, Ethiopian Nurses Association

9. S/r Aster Berhe Head, Midwifery School

10. Dr. Alemu Ferede Family guidance association of Ethiopia

11. Dr. Takele Geressu Ipas

12. Dr. Asselfech Kebede Ethiopian medical doctors association

13. Dr. Bizunesh Tesfaye Ethiopian medical doctors association ethical committee

14. S/r Meselech Assegid Alemaya University

15. Dr. Mesfin G/Ezigabher Jimma University

16. Dr. Million Teshome Resident, AAU

17. Dr. Samson Nigussie Dilla college of health sciences

18. Dr. Yonas Getachew Resident, AAU

19. S/r Kiros Kebede President Ethiopian Nurse Midwifes Association

20. Ato. Teferi Fite Representative, St. Paul's School of Nursing