Pregnancy by Choice

CONTENTS

FOREWORD CELEBRATING THE ACHIEVEMENTS 01 02 03 04 05 06 07 SAVING PREGNANCY WHEN IN A SAFER MAKING INFORMED LOOKING ACCELERATING THE MOTHERS’ BY CHOICE CRISIS WORLD FOR HER DECISIONS AHEAD PROMISE LIVES

Page 04 Page 06 Page 14 Page 26 Page 38 Page 50 Page 62 Page 74 Page 80 04 05

FOREWARD THE FIGHT FOR REPRODUCTIVE RIGHTS AND CHOICES MUST CONTINUE

Imagine a world where every pregnancy is wanted, every Commemorating these The publication also focuses on Fifty years on, the fight for rights and childbirth is safe and every young person’s potential is milestones, it is our pleasure how rights and choices have been choices in reproductive health must fulfilled. Imagine a world where every person can exercise at the heart of the population and continue until the world we imagine, the right and have choices to make safe and informed to present ‘Perspectives – development agenda, yet, at the is the world that we live in right now. decisions on if and when to get married, and whether and A reflection on five decades same time, how thousands of people when to have children. At the United Nations Population of advancements in sexual are still waiting for the promise Let’s continue the unfinished Fund (UNFPA), this is the world we strive to build for and reproductive health in Sri of ICPD to be fulfilled. If we are agenda, and let’s start now. everyone, in every corner of the globe. to achieve the 2030 Agenda for Lanka’. Sustainable Development, if we are In 1973, UNFPA started its operations in Sri Lanka. Since to leave no one behind, then we must then, our combined efforts with the Government of Sri This publication celebrates the address the unfinished business of Lanka, civil society organizations, and development achievements during the last 50 the ICPD agenda. partners has assisted Sri Lanka to achieve remarkable years and earlier, and focuses Ritsu Nacken progress in advancing sexual and reproductive health of its on UNFPA’s key areas of work - Each narrative is a reflection Representative, UNFPA Sri Lanka people. Maternal Health, Family Planning, Comprehensive Sexuality Education, of the potential for sexual and reproductive health and rights This year, 2019, marks two important prevention of Gender-Based Violence, and Providing Humanitarian Relief, to transform the lives of milestones in the field of reproductive health through a compilation of stories from individual women and girls – globally: 50 years since UNFPA began its resilient, inspiring, and empowering and from there, like ripples in operations, and 25 years since the landmark people. The shared insights are from a pond, to drive change that International Conference on Population those who have dedicated years of service to addressing the challenges propels the wellbeing of their and Development (ICPD) in Cairo, which faced in each sphere of UNFPA’s families, communities and represented a paradigm shift for population work, paired with the stories of the the country itself. and development in the recognition that lived realities of women for whom people’s rights, choices, and well-being are the these vital services and far-reaching policies were intended. path to sustainable development.

2003 UNFPA conducts Global Survey to appraise national experiences post-ICPD in Cairo

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CHAPTER 01

SAVING MOTHERS’ LIVES

No mother should die giving birth. Making motherhood safer is a human rights imperative, and it is at the core of UNFPA’s mandate.

In Sri Lanka, continuous investments in maternal health can be traced back to the beginning of the last century. Over the decades, maternal mortality has immensely reduced, resulting in Sri Lanka having the lowest maternal mortality in the South Asia region. Almost every mother in Sri Lanka gives birth in a health facility, and 99 percent of mothers receive antenatal and postnatal care by a skilled health professional.

However, while significant strides have been taken, this is not enough because even one preventable maternal death is too many. Maternal health indicators have been stagnant over the last few years, and most maternal deaths have been preventable. UNFPA works closely with the Government of Sri Lanka to strengthen health systems and to promote international maternal health standards, thereby ensuring that every mother can live to witness the life of their child.

EVERY TIME I GOT PREGNANT, I WAS HOPEFUL, BUT I WAS ALSO AFRAID.

ESHA KAPPARAGE, 52

Esha Kapparage was told five placing Ajith’s sperm directly inside times that a child she desperately Esha’s uterus to increase the chances wanted would never be born. of fertilization. Accompanying the Each miscarriage felt different, yet treatment were a number of injections heartbreakingly familiar: the shortest and oral drugs. Thanks to her training, pregnancy was three months, the Esha was able to simply inject herself. longest four. Sometimes, she knew she had lost the child because of She knew first-hand how excellent the the blood staining her clothes; at healthcare for mothers and children other times it was because the foetal provided by the state was, but felt that monitor revealed that the baby had the hospitals were poorly equipped gone still and lifeless within her to treat couples who needed fertility womb. “Each time it was a great treatments. Asked to provide sperm, emotional blow to me,” she says, “a Ajith was appalled by the conditions loss of all our hopes.” of the toilets he was sent to. There was a clear lack of sensitivity to the Esha had always known she wanted needs of couples such as themselves. to have children. A trained nurse, Switching to the private sector, she had met her husband, Ajith, in however, brought with it its own Peradeniya, where she was attached challenges. Treatments and tests put to the local hospital. The two hit a dent in their budget, and with every it off right away. Ajith was deeply miscarriage, Esha’s heart sank. progressive in his outlook, unlike other men she knew. An English teacher, he “Because I worked in the sector, I could discuss literature and politics knew there were healthcare services for hours. She loved the dark colour of available, but there was no other his skin and the respect with which he system of assisting women to help treated her and all other women. The them cope with the mental pressure two were married after a whirlwind we had to face. There was no courtship. emotional support,” remembers Esha. She adds: “Every time I got pregnant, I After being happily married was hopeful, but I was also afraid.” for a year, Esha and Ajith At the time she was grateful that planned to have a child. Six both his family and her own were months later, it was clear willing to give them some space. Even something was wrong. the neighbours in their village were They went to see a doctor generally respectful. Esha spent hours on the phone with her mother, who and underwent a battery of encouraged her to keep trying. Ajith tests. The diagnosis was was a quietly supportive presence. sub-fertility, which meant He told her that it was her choice, that Esha had a condition and that they would handle it as she wanted. It was the best gift he could of reduced fertility. More give her. tests and treatments were scheduled, with the hope of However, after nine years of having having a child together. her hopes lifted, only to have them so painfully shattered time and time Since Esha was working as a nurse, again, Esha was finally ready to call it she would go for her appointments quits. With Ajith’s support, they began during her breaks at work. They went to think about other options, such as through four rounds of Intrauterine adoption. Insemination (IUI), which involved

They registered with an adoption Another year passed, and centre and put the word out among Esha was pregnant again. their network. They found a possible candidate, a woman who was “We were both over forty,” she expecting twins but could not afford says, admitting that she was to keep both of them. deeply anxious that the child would be born with Down’s Excited now, they began to prepare to welcome a child into their home. They syndrome. They went for turned in their motorcycle for a car tests, but found that the most with a child seat and went shopping reliable one would also be for baby things. the most expensive, and was Then Esha discovered she was simply beyond their means. pregnant for the sixth time. “We decided to take a leap of faith and just take whatever The first month passed, and then the was given to us,” she says. second. The third came and went without incident. When the fourth When Madhuriya, meaning musicality, month went by, Esha finally breathed was born on December 19, 2009, she a sigh of relief. was a completely healthy baby girl.

Nine months later, on April Today, families like Esha’s benefit 24, 2007, their daughter was from the work UNFPA does with born via a C-section. Esha the Government of Sri Lanka to strengthen the capacity of health wept as the doctor held up care providers to deliver quality family a girl. Ajith chose the name planning services, and in conducting Sililari, meaning river or research on subfertility towards stream, for their firstborn. developing a national subfertility package. Ajith would tell people later that their daughter saved Meanwhile, Madhuriya and Sililari their lives. “I think that we are the pride and joy of their parent’s owe a debt to her,” says Esha, lives. Their parents tell them stories about how much they wanted them. “She brought us so much joy. While Madhuriya is outgoing and She is our miracle baby.” Sililari is quiet, together they have a lot of fun. “They play and they quarrel However, fate wasn’t done with them. constantly, but it is wonderful to see them growing up side by side. They A year later, Esha was pregnant again are perfect,” says Esha, beaming with though it seemed that something pride. was wrong. The tests were coming back positive, but the scans showed no trace of the foetus. It took Esha doubling over in pain and being rushed to the hospital for them to realise the pregnancy had been an ectopic, and that the embryo had attached outside the uterus. Esha was rushed into surgery and her fallopian tube removed.

WE EXPANDED THE CONCEPT OF MATERNAL MEDICINE

DR. HARSHALAL RUKKA SENEVIRATNE THROUGH OUR OBSTETRICIAN AND GYNAECOLOGIST UNDERSTANDING

Dr. Harshalal Seneviratne remembers record of maternal mortality OF HOW PREGNANT a time before the ultrasound was in Sri Lanka was at 210 per a common tool in antenatal care. Working as an obstetrician and 10,000 live births in 1881. By gynaecologist in 1970s Sri Lanka, they 1947, a year before Sri Lanka WOMEN ARE relied on the simple stethoscope to gained its independence, the examine pregnant women, collecting number had declined to 166. detailed medical histories and SERIOUSLY conducting comprehensive physical By 2016, the number stood at examinations to help them isolate any 33.8 per 100,000. risks to her health. Diligence was their AFFECTED BY best safety net. It’s a number that doctors pay much attention to. Maternal mortality As a young doctor, Harshalal felt this represents a tragedy for a family. The was a fair ask. He was conscious number also provides insights into the COMPLICATIONS even then of being part of a long overall health of a population and the tradition of practitioners who were quality of its health services. breaking ground in Sri Lanka in the Early photo of midwives advising a young mother during a home visit RELATED TO field of maternal health. In a storied career, Harshalal first became a lecturer in Obstetrics & Gynaecology at the Faculty of “This country has had a In his time lecturing and guiding thousands of students, surgical correction of tubal deficiencies, and later by working Medicine, University of Colombo in DIABETES, Harshalal was instrumental in defining how maternal with a team of Sri Lankan surgical specialists to advance the maternal health record 1975. Between 1978 and 1980, he health was approached in Sri Lanka. In his lectures, he relevant technology. He notes that provision of infertility care since 1881,” he says. In was also Secretary of the UNFPA would emphasize how necessary it was to adopt a holistic remains a necessary component of planning a family. Teaching Program of the Faculty his research paper, Safe approach, considering other factors that might affect a HEART AND LUNG of Medicine, Colombo. He would motherhood in Sri Lanka: woman’s wellbeing which spanned the spectrum from In 1979, Harshalal helped found the first clinic for pregnant rise through the ranks, progressing social, economic and educational development to health women with diabetes, which was then extended to other a 100-year march, written to senior lecturer, then professor, infrastructure and family planning. medical disorders during pregnancy such as hypertension DISEASES, THAN alongside his colleague and finally Dean of the Faculty of and cardiac disease, among others. “We expanded the Medicine. He served in this post till Lalani C. Rajapaksa, His interests extended to all areas of reproductive health. concept of maternal medicine,” he says, adding that he 2011, and retired from the University Harshalal notes that the first From early in his career, he was particularly committed to pushed for physicians to be appointed to key hospitals to of Colombo in 2012. EVER BEFORE. enhancing infertility services. This he did by promoting the focus on this issue, even though he received criticism for 24 25

the decision at the time. “It reflected our understanding of rate in the last 100 years was to the implementation of the new how there were now more women seriously affected by recorded during the 1934 Reproductive Health Programme the complications related to non-communicable diseases, which had been inspired by the including diabetes and heart and lung diseases, than ever -1935 malaria epidemic. developments at the ICPD in 1994 before.” and was to commence in 1997. He Later, as a Member, Fellow, President would later help evaluate UNFPA’s and finally the Patron of the Sri Family Planning Service Delivery in the Harshalal’s generation was building on the Lanka College of Obstetricians & experiences of colleagues who had preceded Estate sector as well as the Country Gynaecologists, Harshalal had ample Programme for Strengthening Family them. This understanding that conversations opportunity to be actively involved Planning Service Delivery. about maternal health had to go beyond with the development of all aspects of reproductive health in Sri Lanka. reproductive issues was not a new one. In It is now well known that Sri Lanka is fact, before 1947, periodic peaks of maternal a model for the South Asian region on He would work closely with the how to provide comprehensive health mortality would coincide with successive UNFPA on multiple occasions, services for women and children epidemics of malaria, which ravaged the including in 1993 when he was with a modest budget. Underpinning country. The highest ever maternal mortality chosen to evaluate UNFPA’s its successes has been a rigorous existing programmes in the run-up system of monitoring and evaluation that has helped identify gaps and address issues with service delivery. While maternal death reporting was a part of the system from 1985, Over the decades, UNFPA has trained health workers in midwifery © UNFPA Sri Lanka Harshalal says that the Maternal Death Surveillance and Response System (MDSR) became truly The process was further informed by the National Harshalal notes that in recent Going forward, Harshalal hopes to exacting and took its present form in Emergency Obstetric and Neonatal Care Needs Assessment years a growing focus on see Sri Lanka reach new highs, and 1992. which was carried out in 2012 with the support of UNFPA. It continue to be a model for the region. would prove pivotal in identifying regional gaps that needed regular training and skills Key will be fostering interdisciplinary Today, every probable maternal death to be addressed to ensure every mother enjoys a safe development has helped innovation, which could birth a new is reported to the Family Health childbirth. The comprehensive study looked into maternal maintain the effectiveness generation of lifesaving techniques Bureau within 24 hours. Sitting on mortality patterns across the country, providing important of the system. However, over and equipment, especially addressing the panel of the first audit, a position insight into regional disparities. those left behind. he would occupy till 2000, Harshalal time, new challenges have contributed to shaping a system A complementary process has been the continual emerged. Even in a context “Our profession is a microcosm of which followed clearly structured strengthening of the nation’s human resources in terms where 99 percent of women society,” says Harshalal. “And all the processes for an immediate of the cadres of Medical Officers of Health (MOH), Public receive antenatal care, challenges we face are reflected in investigation of every maternal death Health Nurses (PHN), Public Health Midwives (PHM), and the real world.” However, he believes at a facility or community level; the Public Health Inspectors (PHI). 99.9 percent deliver in that innovation, commitment and resulting reports fed into a maternal hospitals and 91 percent continual learning will see Sri Lanka death review conducted every six Looking back, Harshalal traces this process back to the De receive post-partum through the years ahead. “We have months at district level, and every year Soysa Lying-in Home, which was established in 1879. He domiciliary care, mothers are come very far, and that is worth at national level. says it laid the foundation for ensuring safe motherhood in still dying in Sri Lanka. The celebrating.” the country and played a major role in the training of the first “This process has developed by cohort of midwives in Sri Lanka - a tradition they have been Maternal Mortality Ratio has evolution rather than revolution,” building on ever since. The establishment of the first health been stagnant for years. says Harshalal, noting that today unit at Kalutara was a major turning point for the provision recommendations are made and of maternal health care and domiciliary care in particular. Harshalal says for Sri Lanka the next then acted upon following each such big challenges are in addressing review. It is a system that has worked Historically, we have seen that maternal mortality regional inequalities and improving extraordinarily well, and at its best, plummeted as trained assistance became more broadly the quality of care across the island. it ensures the efficient correction available, explains the doctor, who played a hands on role in “We have been very vigilant and if you of identified gaps and deficiencies. training and providing support for midwives between 1978 look at the country’s performance “Our ambition was for this to be a and 2012. overall, there is a lot to be proud of,” fact finding exercise and a not a fault says Harshalal, “However, we still have finding one,” he says. an unfinished agenda.”

Nurses conduct sessions on contraceptives to educate women on available options © UNFPA Sri Lanka 26 27

CHAPTER 02

PREGNANCY BY CHOICE

Every woman has the right to decide whether, when, and how many children to have. This is family planning, and it is a human right.

When a woman has the power of choice, she can decide when to complete her education, how to plan her career, and when to start a family. She is empowered to shape her future. This is why the right to plan her family is central to gender equality and women’s empowerment.

Sri Lanka was one of the first countries to recognize the importance of planning a family. In 1937, the first family planning clinic was opened in Sri Lanka, followed by the establishment of the National Family Planning Programme. Over the years, many advancements have taken place, and today, almost every woman in Sri Lanka is knowledgeable about contraceptive methods.

However, challenges exist as contraception and family planning are stigmatized and misunderstood.

Planning a family is a right and a choice. UNFPA works to ensure that every woman is empowered to exercise this right, and to plan her family – so that her pregnancy is by choice, and not by chance.

I HAD ALWAYS WANTED TO BE A MOTHER, BUT THIS MOMENT WAS A CRITICAL MOMENT FOR ME, PROFESSIONALLY. SO, WE DECIDED TO WAIT A YEAR BEFORE WE HAD A CHILD.

RAZNI RAZICK, 30

The first time Razni Razick met wedding. She did this so that the Hisham Haniffa, it was in the street children she had helped could company of their families. They be part of her big day – she had 12 exchanged a few words, but barely flower girls, and 85 young guests from spoke. The second time she met him care homes and the streets in the was at their wedding. first row at her wedding. She couldn’t stop smiling at them. Hisham took Hisham was the last in a long this all in his stride. He even accepted line of prospective grooms. Razni going to work the day after her wedding, as did her own family. Razni had received her first proposal when she was 18 In 2017, Razni won a Ten Outstanding years old, and now she was Young Persons (TOYP) of Sri 28. The decade in between Lanka award from Junior Chamber International for her contribution had been marked by her toward children, world peace and search for a man who was human rights and was one of the educated and kind, and who youngest people to be honoured would accept a wife who was that year. The award brought with it recognition and many opportunities passionate about her field of to travel and to gain skills and work. knowledge in her field. Razni didn’t want to turn any of it down, and Hisham was that man. In fact, he told neither did Hisham. Razni he wanted to marry her not in spite of her work but because of it. “I “I had always wanted to be a mother, was very certain then that he was the but this moment was a critical one for me,” she says, smiling. moment for me, professionally. I wanted to make the most of these Razni’s particular love is working opportunities that would really help with children. Having completed me grow in my career. My husband her schooling in Kandy, she went was even more certain I should make on to gain experience in the field the most of this time, and so, together, in settings like the Early Childhood we decided to wait a year before we Development Centre at the Kandy had a child. We spoke to a doctor, Teaching Hospital, and the Centre for and waited based on medical advice.” Street Children. Later, she became Their parents backed this decision. the Founder and Director of Care Station, an initiative focused on Like Razni, her parents also empowerment, education, self- employment and housing for the had an arranged marriage. homeless. Her father, like Hisham, had also been nothing but Though she was busy at work, Razni supportive of his wife’s used to be quiet about what she was doing. She had very protective ambitions. Razni’s mother parents, and so she chose to hide was the only female lawyer in that she was volunteering in a space their hometown of Gampola that exposed her to poverty, crime at the time, and by all and violence. She managed to keep accounts was admired by the the secret for three whole years, only finally admitting to her family that entire neighbourhood. She she had abandoned a paying job to chose to continue working, work as a volunteer just before her even after she had children.

When Razni was a baby, her mother In her work too, Razni sees the need would simply dress her up and take for raising awareness on family her along to court. Reflecting on this, planning services. Many of the Razni beams with pride and says, young people she works with in the “She did an amazing job of raising us orphanage and care homes have and balancing work with family life. suffered because they did not know She is such an inspiration.” about how to use contraceptives, how sexually transmitted infections are When Razni was 29, she decided she spread or how to prevent unintended was ready to have a child. She was pregnancies. She knows that girls soon pregnant, and both she and bear a disproportionate burden Hisham were delighted. Six months when it comes to the fallout. “Family into her pregnancy, her doctor advised planning is a taboo topic. Very few her to take complete bed rest. Though people speak about it, but we should she was disappointed that she could be more open about it,” says Razni. not keep working, Razni knew it was necessary to rest and took every This is one reason why UNFPA works precaution. Hisham was with her to improve access to reproductive every step of the way. health services, including for marginalized young people. UNFPA Ten weeks later, their son Eesa was supports many aspects of voluntary born. Razni’s entire family turned up to family planning, including procuring celebrate with her. contraceptives, training health professionals to accurately and Today, Eesa is four months sensitively counsel individuals about old. He has Razni and their family planning options, and promoting comprehensive sexuality Hisham wrapped around his education in schools. Razni is living little finger. Razni has also proof that sound knowledge on sexual slowly begun picking up her and reproductive health can help responsibilities at work as promote goals of gender equality, women’s rights and a world where well, and is glad to be back. pregnancy is by choice, and not She has her family’s full chance. support. She and Hisham take turns caring for Eesa, Meanwhile, Razni is grateful that she did not have to choose between her and their parents and siblings career and being a mother; to choose are always happy to babysit. between loving the child in her home As Eesa gets older, Razni and working to protect those who will be able to consider don’t have a home to go back to. Eesa is her own flesh and blood, but those going back to work full time. street kids have a claim on her too. Razni can see how planning “I care so much about the children I her family, and a mutual work with, they are part of me. Some understanding with her of these relationships go back 10 or husband, has played a critical 12 years,” she says. “I could never abandon them, and I’m glad I don’t role in allowing her to pursue have to.” her career.

I WAS DELIGHTED

DR. PRAMILLA SENANAYAKE THAT WE MOVED INTERNATIONAL CONSULTANT IN REPRODUCTIVE HEALTH AWAY FROM

Florence Kannangara was 17 years old to work in the small pox eradication PLAYING A when she married, and 19 years old programme. It was 1975, and rural when she had her daughter Pramilla Bihar offered challenging terrain. in 1942. But when Pramilla turned Memorably, she sometimes had to 17 and her father suggested that ride on an elephant to get to work. “It NUMBERS GAME they find their daughter a husband, was while I was there that I got a call Florence would not even consider it. from Prof. Fred Sai, who offered me “I remember we were at a wedding,” a job with the International Planned TO FOCUSING ON Pramilla recalls. “My parents seldom Parenthood Federation (IPPF).” argued, but she put her foot down and said ‘Over my dead body. She has to Pramilla joined IPPF as its Medical complete her studies first.’” Director, and over the course of EMPOWERING a decade rose to be its Assistant At the time, Pramilla had her eye on Director General, a post she held for 17 medical school, an ambition she had years. Prof. Sai proved to be the best WOMEN, AND nurtured since she was six years old. of mentors and it was while working After graduating from the Faculty of with him that Pramilla found herself Every woman has a choice to decide whether, when, Medicine in Colombo, she went on to at the International Conference on and how many children to have © UNFPA Sri Lanka / Munira Mutaher GIVING THEM A post-graduate studies in London where Population and Development (ICPD) in she pursued her PhD and a diploma in Cairo in 1994. tropical health. recognized “the right of men and women to be informed and The landmark ICPD event was intergovernmental organizations, non- CHOICE. “Women’s health was always a key governmental organizations and the media. to have access to safe, effective, affordable and acceptable the largest intergovernmental methods of family planning of their choice.” This agreement priority for me,” she says, adding that Pramilla was in the thick of it, and remembers she first began running family planning conference on population would lay the foundation for much of UNFPA’s work. clinics while in the UK. “I worked in and development ever held, negotiations that went through till late in the For Pramilla, this was a welcome change. “I was delighted four or five clinics around London, with 179 governments night and reconvened early in the mornings. sometimes from 10 in the morning For the world, it would mark a fundamental that we moved away from playing a numbers game to participating and some focusing on empowering women, and giving them a choice,” till 7 in the evening, putting in two shift in thinking around sexual and hours here or two hours there.” 11,000 registered she says. It was also chiefly memorable for how sexual health participants - from reproductive health rights for women. and rights were finally a part of the conversation. “Up until that point, we had been very backward in talking about it, but After completing her degree, Pramilla governments, UN specialized headed to India where she planned Women’s and adolescents’ rights to contraceptive information you cannot talk about babies and becoming a mother without agencies and organizations, and services was now grounded in basic human rights. ICPD first talking about sex,” she says frankly. 36 37

The conference would have far-reaching The structure of the national year, she received a distinguished implications and in Sri Lanka, it would feed into population and reproductive health service award from the International programme took the shape of a Federation of Gynaecology and the creation of a comprehensive, progressive, pyramid. At the apex was the national Obstetrics (FIGO) for her contribution and new sexual and reproductive health policy on population and reproductive to women’s health globally. She was policy. The formulation of the Population and health. At the next level was the at the peak of her career, and for Reproductive Health Policy in 1998 and the advocacy programme followed by the many it made little sense that she IEC and school reproductive health would come back to Sri Lanka. subsequent development of an Action Plan programme. What followed next at “My parents were against it, they told based on the policy were crucial initiatives. the base was the largest programme, me it was a war-torn country which namely the reproductive health everyone else was leaving. Much as Others included the development of an Advocacy Strategy service delivery. they wanted me back as a daughter, for the promotion of population and development, they didn’t want me to jeopardize Information, Education and Communication (IEC) activities Pramilla would have a chance to my future.” on population and reproductive health and the paradigm see some of these ground realities shift from family planning to the holistic approach of for herself when she returned to However, Pramilla wasn’t coming reproductive health in the service delivery programme. the country in 2003. That same home just for her parents but also because she felt she had a debt to repay to her country. “I called it my payback time,” she says, pointing out that she owed everything to that first, excellent degree paid for Currently, 7.4 percent of married women who want contraception are unable to obtain it © UNFPA Sri Lanka / Ruvin De Silva by Sri Lankan tax payers which was offered to her for free, with no strings attached. She would also engage with UNFPA on adolescent College of Obstetricians and With a demographic transition in play, reproductive health in Sri Lanka. UNFPA sees increasing Gynaecologists and from the it will also be essential for Sri Lanka Once back, it seemed a access to modern contraception among adolescent girls Sri Lankan College of Obstetricians to consider the needs of an elderly natural extension of her as a crucial starting point for improving their long-term and Gynaecologists – possibly the cohort whose medical challenges time with IPPF in London health. It is also essential for improving maternal and only woman to be so honoured. will differ from younger people. “We newborn health, as babies born to very young women face Drawing on this background of diverse need to expand coverage of well to join the Family Planning a higher risk of dying than babies born to older women. experiences, she is able to offer an woman clinics, and we have to work Association (FPA) in Sri Yet adolescents face enormous barriers to accessing important perspective. hard to have the right policies and Lanka. As its President, she reproductive health information and services. investments for these age groups in was part of FPA’s determined “When it comes to women’s place,” says Pramilla. Pramilla’s work in the sector was designed to increase sexual and reproductive efforts to further the Sri Lanka’s national capacity to conduct evidence-based Looking forward, she says Sri conversation around sexual advocacy for incorporating adolescents and youth and health in Sri Lanka today, Lanka has accomplished a great and reproductive health and their human rights and needs in national laws, policies for me the challenges deal, particularly in its efforts to rights on the island. “We and programmes, including in humanitarian settings. are at the two ends of the lower infant and maternal mortality. age spectrum. I am very However, she notes that regional have been a very progressive Now, reflecting on the agency’s broader role, Pramilla adds: disparities exist and remain a cause organisation,” she says. “Even “The UNFPA through its work has strengthened international concerned about teenagers, for concern. “Sri Lanka still has an then, we were talking not just and national protection systems for advancing reproductive as well as women who are unfinished agenda,” she says and for about the health of women, rights, promoting gender equality and non-discrimination over the age of 49.” When her part, Pramilla is far from ready to and addressing gender-based violence.” call it quits. but how to prevent ill-health.” it comes to the former, Today, Pramilla remains a part of the FPA, and in fact serves underage marriages and In other words, we looked at how to as its Vice President, one of 13 honourary positions she unwanted pregnancies address the multitude of issues that holds on boards including the AIDS Foundation Lanka and among young people can fed into a woman’s wellbeing, from the Hemas Preschool project. She is also a council member create health crises that put a healthy lifestyle, to regular cancer of the Sri Lanka Medical Association. screenings and awareness around young women in danger of changes in their bodies such as As a mark of all she has achieved over decades of work, their lives, and can deprive menopause, as well as the treatment Pramilla has received honorary degrees from the Royal them of future growth and of conditions like heart disease and College of Obstetricians & Gynaecologists (UK), American diabetes. wellbeing, she says.

97% of married women in Sri Lanka are knowledgable about the contraceptive pill © FPA Sri Lanka 38 39

CHAPTER 03

WHEN IN CRISIS

Every humanitarian crisis—due to conflict or natural disaster—causes support systems to break down. This increases vulnerabilities, especially of women and girls, increasing the need for protection services to ensure the wellbeing, security, and health of those affected. In such crisis situations, when sexual and reproductive health and protection needs are overlooked, the consequences can be staggering.

Pregnant women risk life-threatening complications without access to reproductive health services. Women and girls may lose access to family planning, exposing them to unwanted pregnancies in perilous conditions. Women and young people also become more vulnerable to sexual violence, exploitation and HIV infection and the hygiene needs of women and girls of reproductive age are often neglected.

In recent years Sri Lanka, a post-conflict society, has begun to experience more extreme weather patterns, with each instance stretching government resources. Whether it be floods or droughts, the island’s experiences reflect how humanitarian emergencies around the world today are appearing in unprecedented frequency and intensity.

In such emergency situations, UNFPA supports the Government of Sri Lanka to ensure that the affected populations are aware of and have access to essential sexual and reproductive health services. UNFPA also works closely with other UN agencies and partners to ensure that reproductive health and gender are integrated into emergency response and preparedness. This ensures that the needs of women and young people are served through a continuum approach.

EVERYDAY WE LIVED IN FEAR THAT WE WILL BE BOMBED. WE WERE ALONE, AND I HAD NO ONE OTHER THAN MY HUSBAND. MY PREGNANCY WAS NOT THE HAPPIEST MOMENT LIKE IT WOULD BE FOR OTHER MOTHERS.

SUGUNAKUMARY RANJITH, 56

For her first son’s second birthday, Suguna remembers the whole period Sugana baked a cake herself. She passing in a haze of worry. “I was took what flour she could find, and not thinking of my child’s future,” she poured the batter into a container says. “We were worried about daily which she then buried in loose sand life, about whether we would survive.” and surrounded with wood. It was the However, in the moment when her only oven she could muster in a year son Mathurrangann was born, she of displacement and heartbreak. felt a quiet joy. At the entrance to the operation room, Ranjit stood waiting She and her small family had been anxiously to hold his first born. living in exile, having fled the fighting between the militant separatist In the days that followed, organization Liberation Tigers of Tamil Suguna struggled to breastfeed. Eelam (LTTE) and the Sri Lankan Undernourished herself, her milk ran State. Suguna’s whole neighbourhood dry and they had to switch to formula had abandoned their homes in the for the baby. It cost Rs. 1,800 at the October of 1995, joining an exodus of time – more than half of what they had people leaving Jaffna on foot. to live on for the month. There was no question of pampers, and so they made do with cloth, even though the soap When she first realised she that was needed to wash it was another was pregnant, Suguna was great expense. In the sleepless nights excited, but also frightened. that followed Mathurrangann’s birth, At the time, they lived in Suguna remembers that she and Ranjit had their first quarrel. “We experienced Jaffna, comfortingly close to everything then: frustration and fear and the public hospital. However, happiness, all at the same time.” every day the fighting drew However, by the time they were closer. displaced a year later, Mathurrangann had grown into a happy, sturdy little “Everyday we lived in fear that we will child. Suguna carried him on her hip be bombed. We were alone, and I had as they left Jaffna. With them they no one other than my husband. It was also carried everything they needed not the happiest moment like it would – it would have to see them through be for other mothers,” says Suguna. multiple rounds of displacement. When they paused, they would rely on mud She was grateful that houses and small dug wells for shelter somehow, in the middle of and water. Suguna thinks they were all this, healthcare was still displaced nine times or maybe even more – she lost count along the way. available. Midwives visited her at home and at the Four years later, Suguna was hospital, they ran the basic pregnant again. They had at tests. this time settled in a village During one of her check-ups, Suguna 50km away from the main was told her baby was in a breech town of Kilinochchi. Suguna position and that she would need a had found work as a teacher, caesarean. She was admitted to the and their income was more hospital. “I had complete confidence in the doctors,” she says, “this was a reliable. Their new home teaching hospital and I knew they were also had room for a garden. good, but the hospital itself was in poor Suguna grew vegetables condition.” Patients were packed into beds and the toilets were unclean.

Such as beans and manioc, few days for the family, especially as well as spinach and because as a man, Ranjit was not allowed into the ward, and Suguna murunga. All in all, she went had to manage everything herself. into this pregnancy feeling stronger. The war—one of the bloodiest and longest running in the Though her pregnancy had been a relatively peaceful one, Suguna South Asian region—came was aware that the fighting was to a close in 2009. Through intensifying around them. In February, humanitarian crises such as as the country marked the anniversary these, UNFPA has extended of its independence, the state Armed Forces and the LTTE clashed in its support to ensure that Kilinochchi. every woman experiences a safe birth, even in the When she went into labour in February most unsafe conditions. 1998, it coincided with a particularly In Sri Lanka, almost every heavy round of bombing and shelling. Already in severe pain, Suguna leaned mother delivers her child in a on Ranjit as she stumbled to their healthcare facility supported neighbour’s car to make the 50km by a skilled professional. trip to hospital. The roads were This is a result of continuous terrible, and she felt every jolt send an agonizing spike of pain through her advancements in maternal body. It took them six hours to reach healthcare over the decades. the hospital. Meanwhile, Suguna and her family When they got there, they found no have thrived. She still remembers doctors on call. All the beds were Mathurrangann’s amazement when occupied, and Suguna was shown a he encountered electricity for the first spot on the floor where would have time in his life – he was four years old. to lie down and wait. She knew the child she carried was too large for Today, women deliver their babies a natural birth – it would have to be with a female counterpart by their another caesarean. “I was panicking, side, a policy change that Suguna my husband was panicking. I was in feels she made a small contribution severe pain, but there was nothing we towards by fighting for her rights. could do but wait.” “We had lost everything,” she says, To their eternal good fortune, a doctor “but we still had our lives. Everyone in came rushing in. Soon after, they my family was safe. I feel if you have welcomed little Subeedshan into the your life and your courage, then that world. is the primary thing. That is all you need.” Mother and son spent the next three days in hospital. Though Suguna was recovering, soon after his birth, Subeedshan was diagnosed with malaria. His frail body writhed in the throes of a serious fever and he had diarrhoea which threatened to leach his body of nutrients. It was a difficult

WE NO LONGER

RIZVINA MORSETH DE ALWIS THINK PURELY UNFPA REPRESENTATIVE, CAMBODIA IN TERMS OF

The first moment Rizvina where she was responsible for PROVIDING RELIEF; Morseth De Alwis realized designing, implementing and monitoring execution of the agency’s that something might be programmes, including the post- wrong was when rumours tsunami project on Gender-based INSTEAD WE began circulating that the Violence. “I had always been very “ocean had flowed into the interested in issues relating to women’s empowerment and gender FOCUS ON THE land.” Turning on the TV did equality and so it felt like a natural fit,” not help at first – no one she says. really knew what a tsunami NEXUS OF PEACE, was, or what to expect. But In the wake of the tsunami, coastal communities across the island were the images flickering on still picking up the pieces of their lives. the screen spoke of near UNFPA had already begun helping to DEVELOPMENT AND catastrophic devastation. restore vital infrastructure needed to provide health services. Meanwhile, UNFPA provides dignity kits for women and girls of reproductive It was 2004, and Rizvina was the the UNFPA team had commissioned age to maintain their health and hygiene during disasters © UNFPA Sri Lanka / Christian Hutter HUMANITARIAN Head of the UN Inter-Agency Support a gender audit, and it confirmed what Unit (IASU) of the UN Resident Rizvina had already suspected. There Coordinator’s Office in was a great need for psychosocial In crisis situations, women and children are Already, more women than men had died in the tsunami. WORK. Sri Lanka. They immediately interventions, and for policies to more likely to be trafficked, or recruited as sex Unable to stay afloat because they were tangled in their saris swung into action, attempting address a spike in gender-based or simply because they had never been given the chance to coordinate relief efforts that violence. workers and the incidence of sexual assault to learn to swim because of their traditional gendered covered the spectrum from national and violence against women increases. upbringing, women struggled to escape the waves. In such to international, government to “Overall, the relief provided had With little protection available, women and cases, where a family had lost a wife and mother, children civil society. It would prove a near been largely gender neutral,” Rizvina girls become vulnerable to STIs and HIV. were sometimes left in the care of male guardians who overwhelming challenge. reflects, but they were beginning might be ill-equipped to cope. “We thought there might to see quite clearly how women Without access to contraceptives, women be a silver lining and that this would be an opportunity to As Sri Lanka moved from relief and young people were especially face the risk of unintended pregnancies and transform gender roles, but it did not work out like that,” says to recovery, Rizvina took up a vulnerable in the aftermath of such a in such circumstances could be pushed into Rizvina ruefully. Instead, in such cases, the eldest girl child new post at the UNFPA in 2005 crisis. desperation, seeking backroom abortions, was sometimes required to step into her mother’s shoes and which could then prove fatal. care for her siblings - whether or not she knew how to. 48 49

Families, concerned that their girls were unsafe, sometimes and their homes again to the if these needs were not met, their chose to marry them off early, often pairing these child waves. It was just tragic,” mobility was restricted,” says Rizvina, brides with older widowers. Some would then become explaining that this then meant that mothers while they were still adolescents. This one act Rizvina recalls. women were reluctant to come could derail their lives, delaying, postponing or abandoning forward to access services, receive education and ensuring they would never be independent or In the short-term, living in relief supplies or engage with the seek employment. communal spaces also stripped authorities or camp management. As privacy from women, and this was a result, they, and their most pressing particularly serious when it came to needs, were not considered. Some of the areas worst affected had also sanitation facilities. The team were been riven by the conflict in the preceding understanding how critical it was to The repercussions went on and on, decades, and here women were simply separate toilets for men and women, infinitely complex, yet clear on this struggling to regroup. “There were so many and to ensure they were well lit and one point: more needed to be done for secure. Women and girls also had the most vulnerable. who had lost family members and homes specific needs, such as sanitary to the war, and then lost more family members pads or birth control pills which they Responding to these needs, Rizvina could not do without. “Essentially, helped establish a forum against Gender-based Violence to coordinate different interventions initiated by different stakeholders—the first of its kind in Sri Lanka—which continues to date under the leadership of UNFPA A woman attends a health clinic in the wake of the Tsunami © UNFPA Sri Lanka with over 50 members representing the Government, other UN Agencies, civil society, and activists. In Ampara, Rizvina remembers watching as the women “We weren’t a big humanitarian agency Deputy Representative for the UNFPA, used their saris to create screens to cordon off a safe space before, but now it is very much part of these lessons have proved invaluable. Another pilot project at the Matara behind which they could retreat. “It became very obvious what we do. We no longer think purely “It really helps that some of these Hospital modelled a health sector that they needed a designated area within the larger camp in terms of providing relief; instead ideas resonate so much with my own response to Gender-based Violence where they could just pause or even sit and grieve in private,” we focus on the nexus of peace, beliefs,” says Rizvina today. with the setting up of a centre called says Rizvina, adding that the team immediately began development and humanitarian work.” ‘Mithuru Piyasa’ becoming the first creating women’s spaces or women’s centres which was a “I truly believe that of its kind. It was subsequently relatively new idea at the time. Rizvina feels this is truer than ever reproductive health and rights scaled up and mainstreamed into the in Sri Lanka today where the country are essential to women’s UNFPA country programme. Today, Rizvina came out of the experience thinking is facing challenges from extreme every state hospital has a ‘Mithuru weather conditions to political turmoil. empowerment.” And when very differently about relief and recovery. It Piyasa’ centre established, which it comes to preparedness, provides immediate access to safety was clear that while aid could play a vital role, “Our interventions are now taken to much is achieved by building for women who face any form of much more had to be done before disaster a different level. We are engaging strong institutions and violence. struck. This approach had gained momentum at the upstream level, looking at comprehensive strategies ever since the International Conference on emergency preparedness or conflict During humanitarian prevention and investing in peace. that are inclusive and Population and Development in 1994, which emergencies, UNFPA began The programme approach and even equitable. signalled the shift from controlling fertility to proactively distributing the vocabulary we use is changing talking about women and couples having the in that direction. We want to make ‘Dignity Kits’ and ‘Maternity “Those frameworks become very power of choice. more sustainable investments in important when we have these Kits’, which include basic development.” setbacks,” she says, emphasizing the items for women and girls “For us at UNFPA, and for me personally, we saw the need to invest in strengthening local of reproductive age, and link very clearly, in an almost tactile way,” recalls Rizvina, For Rizvina, this is a critical shift and institutions and creating equitable perhaps the most essential step to pregnant mothers and explaining that it was evident that one could not separate policies. “The extent to which those reproductive health and rights from the agenda of advancing toward really helping women and are resilient will tell us whether we can

mothers of newborns. gender equality and women’s empowerment. young people around the world. In her rise above this crisis or not.” subsequent postings in Laos, North Korea and Cambodia, where she has served as the Representative and

UNFPA supported relocation of this maternity hospital in Galle, which was destroyed by the 2004 Tsunami © UN Photo/Evan Schneider 50 51

CHAPTER 04

A SAFER WORLD FOR HER

Violence against women and girls is one of the most prevalent human rights violations in the world. It knows no social, economic or national boundaries.

A UNFPA study conducted in five provinces in Sri Lanka, found that one in three female homicides are related to intimate partner violence, and 69 percent of such incidences go unreported.

In recent years, Sri Lanka’s health sector has begun to document how victims of violence can suffer sexual and reproductive health consequences, including forced pregnancies, sexually transmitted infections, and even death.

Gender-based violence is not only a violation of individual women’s and girls’ rights. The impunity enjoyed by perpetrators, and the fear generated by their actions, has an effect on all women and girls. It also takes a toll on a global level, stunting the contributions women and girls can make to international development, peace and progress.

As the Co-Chair of the National Forum Against Gender-based Violence, UNFPA plays a key role in ensuring a world free of violence for all women and girls in Sri Lanka. This work includes capacity building of officials in public institutions and engaging with civil society and mutlistakeholders to promote the right of all women and girls to live free of violence and abuse.

WE ARE ALWAYS ASKING GIRLS TO BE BRAVE AND CAREFUL. INSTEAD, LET’S TEACH BOYS NOT TO HARASS GIRLS.

ANUTHARSI LINGANATHAN, 29

Anutharsi Linganathan remembers harassment and the only way waking up to find a stranger touching her. to make it stop was to leave. This was not the first time it had “Girls won’t go to the police,” happened, especially on the late night she says. “It does not feel like bus from Colombo to Jaffna. At least a comfortable place for us.” this time she wasn’t alone, she had her friends with her. Her colleague In any case, the women were treated challenged the man who had pawed like interlopers at the news desk. Most Anu, asking him to move. He would women could not work late, and had not. Soon the whole bus was involved, protective families who objected to and to Anu’s amazement some their going out into the field. Once people supported the man who had they married, their husbands would groped her. She called 119, and found often require them to quit working. more hostile voices on the other end of the line: ‘What is your ID number?’ And then there was the fact that they wanted to know, seemingly politics wasn’t seen as a beat completely disinterested in her for women, who were instead attacker. encouraged to cover soft stories – to write about health and lifestyle Though Anu protested it was about or about the latest film. “They said the man and not about her, it didn’t difficult issues are suitable for men, help. Eventually, her little group got off and that girls can’t handle these kinds the bus and took a taxi the rest of the of stories.” way. When Anu got home, she didn’t discuss the incident. “I could not tell Anu disagreed with her my mother about it,” she says. “They were already worried about my safety colleagues that women didn’t and security.” belong at newsrooms. She felt girls simply needed the Anu’s choice of journalism as opportunity to learn. She a career wasn’t one that her also could see that women family approved. “Sometimes might bring a different, more I would have to work till empathetic approach to their 11pm, and my family thought reporting. it was not secure. It is a cultural thing, also,” she says. In fact, it was Anu’s early exposure to the realities of war reporting that “People do not understand had prompted her to enter journalism why a girl may need to travel in the first place. Growing up in alone or live alone.” northern Sri Lanka, Anu’s family had been caught in the conflict. They were displaced multiple times due At work, Anu and her female to the fighting. When Anu picked up colleagues faced a different the newspapers, she would see the set of challenges. There was same incident reported in different the occasional editor who ways, some of which seemed deeply irresponsible to her. “I wanted to would harass his juniors become a journalist, because I wanted with impunity – girls quit to see ethical reporting,” she says. simply because there was no mechanism to address sexual

© UNFPA Sri Lanka / Shehan Obeysekera This was on her mind when Anu left differently from her three brothers. school and began looking around for “They had the mentality that boys can the right journalism programme. She do everything, but girls needed to be found that a few options existed. Her protected,” says Anu ruefully. Anu saw parents wanted her to study in Jaffna, their perspectives as being rooted in where they had been displaced for a kind of cultural violence, which also a brief period. They knew the people included dimensions of caste and there, they knew the culture. However, class. that was exactly what Anu didn’t want for herself. Anu’s time in media studies helped her see how these “I wanted exposure to new communities and new experiences,” forces were at play not just she says, explaining that she applied in the work she did, but in the to other programmes without broader world. Today, she is a informing anyone. When she was lecturer at Jaffna University, accepted in to the Trincomalee Campus of Eastern University, it was though she also remains a the first her family knew of her plans. freelance journalist. With years of experience under “I think everyone expected me to be a her belt, Anu says she is homely girl, but I didn’t want that,” she says. When Anu went to university, still determined to pursue she found herself challenged again. her passion for journalism. Being ‘ragged’ for the first time, she She thinks women will cried when her new seniors spoke change the sector simply by to her in foul language, which they then demanded that she repeat. demonstrating again, and Away from home, she also began to again, that they won’t baulk at experience more routine harassment the challenges. from strangers. “I was very protected when I was growing up,” says Anu, After years of trying to change her “Everyone in Vavuniya were familiar mind, her family accepts her career. people, but in the buses it was the “My mother finally understood that unknown people who would harass this is my passion,” she says. Though us.” she has fought for this for so long, Anu doesn’t know if this will change Anu is far from alone. In 2015, UNFPA when she becomes someone’s wife. initiated a national survey on sexual Many of her friends left work to stay harassment in public transport to at home after they tied the knot. understand the prevalence of this issue. Preliminary data revealed that However, she believes that women 90 percent of female respondents can be a powerful presence in the were affected by sexual harassment home. “In the future, I will teach my in public buses and trains at least sons to respect their sisters,” she once in their lifetime, thus highlighting says. “We are always asking girls to be the severity of the problem. brave and careful. Instead, let’s teach boys not to harass girls.” Such experiences seemed confirmation of all the things that Anu’s grandparents, the most conservative people in her family, had said to her. At home, they were the only ones who treated Anu

EVERYONE RECOGNIZES PHYSICAL VIOLENCE

DR. LAKSHMEN SENANAYAKE – FRACTURES, EAR CONSULTANT ON GENDER-BASED VIOLENCE DRUMS RUPTURING,

As a young medical student, It was this last factor among many EYES BLEEDING. Dr. Lakshmen Senenayake was that would convince Lakshmen oblivious to the fact that he was living that the health system was uniquely in a patriarchal society, one which placed to assist women suffering affected individuals in profound from gender-based violence. BUT WHAT WOMEN ways. It was only when he started practicing medicine, particularly, as an A hospital is the single place where obstetrician and gynaecologist that women of every background, age and EXPERIENCE this truly became evident. “It became ethnicity would come to, not once, but very clear to me that gender, and multiple times. Therefore, providers gender attitudes, have a significant working in healthcare are strategically MENTALLY AND role to play in health care,” he says. placed to detect women and girls living with violence, care for them and Lakshmen would argue refer them on to other services. that domestic violence, EMOTIONALLY, After being in active clinical practice particularly during pregnancy, of Obstetrics and Gynaecology for The ‘Mithuru Piyasa’ billboards around the country had to be recognised as a more than 30 years, Lakshmen would highlight the effects of domestic violence on children © UNFPA Sri Lanka WHICH IS national and a global health shift his interests more towards the concern. It is associated subject of gender-based violence. Over the years, Lakshmen has worked with serious negative health based violence and where necessary, were referred to a The experiences gained from this project would lead to the SIGNIFICANT, closely with UNFPA to help shape centre managed by the NGO ‘Sarvodaya’ for counselling evolution of a model gender-based violence service point, impacts such as miscarriage initiatives of the Ministry of Health, services. Training was provided to hospital field staff as well. titled ‘Mithuru Piyasa’ in Sinhala, and ‘Natpu Nilayam’ in and growth restriction, and to help address this serious issue – Tamil, meaning ‘Friendly Abode’. one of the earliest in Sri Lanka being OFTEN GOES could even lead to fatal “At the time, there was not much research data the multicountry pilot project in the consequences for women and or information on the existence of gender- The first service point was established at the Matara island’s North Central province. Base Hospital by the Ministry of Health in 2005 with the their unborn foetus. based violence in Sri Lanka. What we learned assistance of UNFPA. Despite many challenges, the model UNRECOGNISED. All women attending the antenatal from the pilot was that a significant number of was widely embraced and many desks would be established and gynaecological clinics of women were subject to abuse, and that they in state hospitals across the island. Today, the network of Anuradhapura and Thambuttegama were willing to use services if they had access ‘Mithuru Piyasa’ / ‘Natpu Nilayam’ centres cover 63 hospitals hospitals were screened for gender- across Sri Lanka. to them,” says Lakshmen. 60 61

Though the pilot project was necessarily modest, it would Awareness was growing, as processes in families, in villages, have an outsized impact. Critically, the data collected was previously scattered efforts came in political parties, in the business enough to convince the appointed Parliamentary Sub together to create momentum. As a sector and in the civil society as a Committee to review the Prevention of Domestic Violence Member of the National Committee whole. They should not be passive Act (2005), which was subsequently passed by the Sri on Prevention of Violence, at the participants in the process, but an Lankan Parliament. Ministry of Health, Lakshmen would integral part of the machinery of author the chapters on Gender-based power. In short, what is needed is a Since then the Family Health Bureau of the Ministry of violence and Domestic violence social upheaval where women would Health, has approached the subject in a systemic and for the first ever Sri Lanka Report be perceived as equals.’ comprehensive manner with the technical and financial on Violence and Health, which was support of UNFPA and the World Health Organization published in 2008. However, the ground realities did not (WHO). Increasingly, Sri Lanka’s response to gender-based go unnoticed. In the same report, violence was taking a multi-sectoral form, with various He would write that to achieve a Lakshmen mentions that a high stakeholders stepping forward to grapple with the issue. genuinely equitable role for women, percentage of incidents of violence Countries such as Nepal, Afghanistan and the Maldives ‘we need to ensure that they are against women are not reported made study visits to observe the institutionalization empowered and become equal to authorities. Lakshmen, goes on mechanisms in the health sector that worked in Sri Lanka. partners in the decision-making to explain that violence could and did take many forms, including physical, sexual, emotional, economic, and psychological abuse. “The ramifications go way beyond what we think,” says Lakshmen. “Everyone UNFPA is one of the lead UN agency’s working to further gender equality and women’s empowerment © UNFPA Sri Lanka / Munira Mutaher recognizes physical violence – fractures, ear drums rupturing, eyes bleeding – everybody knows that when left unchecked, it had the effect of As reflected in the National Action Plan, As new challenges continue what it looks like. But what women curating women’s choices and rights especially the authorities were also becoming to emerge, the society experience mentally and emotionally, aware of emerging concerns. over a long period, which is significant, in relation to sexuality and reproduction. While policies were increasingly in can no longer afford to be often goes unrecognised.” place, implementation still lagged playing a game of patience “Some of the costs incurred due to gender-based violence behind. Lakshmen felt every level of and masterly inactivity. are tangible and can be counted,” he says, noting that these His work would also expand beyond government had to be sensitised to “We must not be blind to the health sector. Lakshmen, along could include accessing medical or legal services. There are the issue if there was any hope that with Sriyani Perera, would facilitate also issues around productivity at work and absenteeism. attitudes in the wider society might gender-based violence, or the development of the Policy Then came the costs for which there are no numbers. change. Accordingly, Lakshmen make the mistake of denying Framework and National Plan of Suffering, the loss of dignity and experience of fear are supported efforts by UNFPA to raise that it exists in Sri Lanka,” intangible, but very real. Last but not least is the adverse Action to address Sexual and awareness on addressing gender- Lakshmen emphasises. “If we Gender-based violence in Sri Lanka impact witnessing abuse could have on children. based violence with the staff of (2016 – 2020) for the Ministry of important establishments such as want to help our women and Women and Child Affairs. The plan We could see that these ‘adverse childhood experiences’ the Human Rights Commission, Legal children, if we want to see covered nine sectors, each headed by affect the two sexes differently. Boys might take away an Aid Commission and Public Service them blossom as productive idea of masculinity in its most toxic form, of how men could a lead Ministry, and was ratified by the Commission. citizens, then we must act Cabinet without any amendments. exert control over their wives and family members. Girls, on now.” the other hand, might normalize violence and believe it is a “Today, critically, we also have to Increasingly, gender- part of being a woman and running a family. So the cycle understand that gender-based violence would perpetuate itself generation after generation. based violence was being continues to evolve and manifest in recognized as a human different forms. 25 years ago, we talked Children from such families are also likely to struggle both mostly about physical violence by rights violation and a public inside and outside the home and are more likely to pursue perpetrators known to women, but now health problem with legal, risk taking behaviours in an effort to escape the unpleasant we are seeing other forms of violence environment at home. “Without realising this, these men, proliferating such as cyber violence and social, cultural, economic and who were beating women, were unwittingly directing their psychological dimensions. sexual violence on public transport. own children towards their downfall,” says Lakshmen. As the country’s landscape changes, Lakshmen would argue so does the modus operandi of the perpetrators,” cautions Lakshmen.

Worldwide, it is estimated that 1 in 3 women will experience physical or emotional abuse in her lifetime © UNFPA Sri Lanka / Ruvin De Silva 62 63

CHAPTER 05

MAKING INFORMED DECISIONS

Every young person will one day have life-changing decisions to make about their bodies, and sexual and reproductive health in general. Yet, research shows that the majority of youth and adolescents lack the knowledge required to make these decisions responsibly.

This is why comprehensive sexuality education is so important. Providing accurate and age-appropriate information about human development, anatomy and reproductive health, as well as information about contraception, childbirth and sexually transmitted infections (STIs), including HIV, can change a young person’s life and help him or her achieve their fullest potential.

In Sri Lanka, more than 50 percent of youth lack knowledge about the reproductive system of the opposite sex. Too many young people receive confusing and conflicting information about relationships and sex as they transition from childhood to adulthood.

Comprehensive sexuality education is a curriculum-based process of teaching and learning. It aims to equip young people with knowledge, skills, attitudes, and values that empower them to realize their health, well-being and dignity, and to develop respectful social, romantic and sexual relationships.

UNFPA advocates for ensuring every young person is equipped with the knowledge to make informed decisions about their body. In doing so, UNFPA works with the Ministry of Education to increase capacity of delivering age-appropriate sexuality education for youth.

IF YOU ARE NOT GETTING INFORMATION FROM YOUR PARENTS, AND YOU ARE NOT GETTING IT FROM YOUR SCHOOL, THEN YOU ARE GETTING IT FROM YOUR FRIENDS – AND IT MAY NOT BE THE CORRECT INFORMATION.

SANDAMALI RAJIKA SILVA, 42

Sandamali Rajika Silva still remembers It is for this reason that UNFPA promotes her first – and only – sexuality education comprehensive sexuality education, class. She was in Grade 8, surrounded which provides vital information and by her friends. Their teacher was then goes beyond it to explore and clearly uncomfortable. “She looked like nurture positive values regarding their someone who was quite reluctant, like sexual and reproductive health. This she had been compelled to talk about education includes discussions about it,” says Sandamali. The class consisted family life, relationships, culture and essentially of an introduction to the gender roles, and also addresses human reproductive system, which meant rights, gender equality, and threats such labelling a diagram on the board – and as discrimination and sexual abuse. that was it. Taken together, Sandamali believes At home, Sandamali wouldn’t this information can help young people dare bring up the subject with develop self-esteem and life skills that encourage critical thinking, clear her mother, who was quite a communication, responsible decision- stern lady. While Sandamali’s making and respectful behaviour. For father doted on her, this her part, the mother of three has already wasn’t the kind of the thing begun preparing the girls for their menstrual cycle, explaining what they they discussed either. It isn’t should expect and what they should do if something she holds against they begin to bleed. her parents. “That was just their way,” she says. She has also sat them down and had a frank conversation about what So her best sources were her inappropriate touching is and when an classmates and cousins. “This was adult might not have their best interests the case for most of my friends, to be at heart. honest. If you are not getting information from your parents, and you are not It wasn’t the easiest getting it from your school, then you are conversation to have, but getting it from your friends, and it may Sandamali knew enough of not be the correct information,” she says. what was happening in the When Sandamali had children wider world to know she had of her own, she didn’t want to ensure the girls didn’t fall to see the cycle repeated. victim to a sexual predator. There was nothing she could do about how it was taught “We knew it could be anyone, at their school, but she it could even be someone always wanted to have an they knew, and so we had to open relationship with her really talk to them. Once it daughters; she wanted them happens, it is a scar and you to be able to tell her anything. can’t undo it. I never wanted to regret not speaking to Swasha, Yahali and Nehali were growing them when I had a chance.” up so fast. Like any pre-teen, they had many questions and were curious about It was also clear that her children lived in their own bodies. Social stigma, however, a different world from the one Sandamali might mean they were left to fumble in grew up in. the dark.

She is already in a small tussle with her The world isn’t fair and she knows eldest daughter who feels ready for her girls face different, and more serious own phone – after all, her friend and consequences than boys. She wanted cousin who are the same age have their to be upfront about the risks and the own phones already. Sandamali is less long-term implications of any choices than keen. Laughing, she admits she has they make now. Realising that she told Swasha that she may have to wait a can’t be there every minute of their year or two. day, supervising everything they do, Sandamali feels like the best approach She says this with an awareness that it might really be to just empower the can be hard to protect children online. girls to make the right decisions for She knows that there are predators themselves. who try to groom young people, and can be very clever about manipulating If they end up doing something she them. She is also concerned about disapproves of, Sandamali still wants peer pressure and the increase in them to be able to come and talk to young people sharing photographs with her about it. At least then she knows each other. Children may not always that they could handle the problem fully grasp what is going, or what the together and that her children won’t be consequences are, and Sandamali alone, confused or frightened. “If you are doesn’t want something online that confident about the relationship, if you could leave her girls vulnerable or open say to her, ‘I do have faith in you,’ then to exploitation. your children don’t want to disappoint you,” she says. The landscape is changing so rapidly that parents can struggle to know how to She is grateful that her children’s school protect their children. Staying on top of now offers counselling services to what the latest social media fad is, can children who may have been abused, feel impossible. but she says this isn’t a substitute for comprehensive sexuality education. “When I was young, I was very However, she feels the subject may protected,” says Sandamali, explaining require a different approach from the that there was no socialising with boys. usual curriculum and should be delivered “Just to see a boy at a party was like by teachers who specialise in it and are magic, and that’s definitely not true in able to put young people at ease. She this era,” she says ruefully. In contrast, also acknowledges that parents need to she wants Swasha, Nehali and Yahali do most of the work, and feels like home to have a healthy understanding of their is where these conversations need to own bodies and their emotions as they start. grow up. “I know what it was like for me growing While some parents choose up, and I don’t want them to have the to focus on promoting same problems,” says Sandamali. “I want them to understand that it is about loving abstinence, Sandamali thinks yourself. If you start loving yourself then that it doesn’t really work like you know certain things might harm you, that. “It’s not like telling them and so you choose more wisely.” ‘don’t steal!’ This is connected with feelings, and I know that one day my girls might meet someone they care about. You can’t cage them.”

PEOPLE ALWAYS SEEMED TO ASSUME SENEL WANNIARACHCHI CO-FOUNDER HASHTAG GENERATION THAT IT WAS ABOUT HOW TO HAVE SEX. ‘Can you get pregnant by sharing a bar When finally faced with a room of of soap?’ young people, Senel did his best ‘An adult sometimes touches my to draw on his own experiences to WE HAD TO EXPLAIN private parts, is it okay?’ design a programme that would ‘Can you get infected with HIV if resonate with them. It could start out someone living with HIV uses the awkward, but once the conversation THAT WE WERE same swimming pool as you?’ began, students tended to become interested, because these were After all these years, Senel answers to questions they actually Wanniarachchi still remembers the had. At the end of every training, the ACTUALLY TALKING questions. As the Manager of Youth team would invite participants to write Programmes at the Family Planning any other questions they had on a chit Association of Sri Lanka between and send it to the front. Hundreds of ABOUT ISSUES LIKE 2016 and 2018, Senel had the slips would be passed down the rows. primary responsibility of steering a national programme, which provided Some of the questions GENDER EQUALITY, comprehensive sexuality education Engaging men and boys in conversations around sexual and reproductive were surprisingly naïve, but © UNFPA Sri Lanka / Munira Mutaher for over 20,000 young people. health is crucial in advancing gender equality Senel could relate to these In a relatively conservative culture, students. “I had been a CONSENT AND the effort brought with it specific university student myself, Senel’s route to this moment had been a largely unplanned Health reported that 658 abortions were carried out daily in challenges – starting with access to and so these things didn’t one. Starting out as a young reporter, his interests were Sri Lanka, adding up to 240,170 unsafe abortions annually. schools that did not always take to surprise me, particularly diverse, but gradually became more focused on rights and SEXUAL RIGHTS. the idea of young people coming in to development issues. At one point, he wrote a weekly column How and why were there so many unwanted talk to students about comprehensive because I was also for a local newspaper, which touched on topics such as sexuality education (CSE). The experiencing them or seeing gender equality and sexual orientation, which he saw little of pregnancies taking place in Sri Lanka? This was team expected this, and prepared them played out around me,” in mainstream media. the kind of information that hooked Senel and workarounds such as going through he says. “For the most part, left him feeling compelled to write about it. It was a supportive Member of Parliament As he wrote, he also learned and what he discovered could these efforts that first brought him to the attention or taking along a sympathetic senior there was no CSE in our still surprise him at times. One instance of this was the of the Family Planning Association (FPA), where doctor. schools and that was just data around abortions. Sri Lanka has some of the strictest something we grew up with.” abortion laws in the world. In 2016, alone the Ministry of he initially joined as a volunteer in 2014. 72 73

He would be invited in that capacity by UNFPA to attend the “We say young people are important, actually talking about issues like Youth Engagement and Gender Equality conference (2014) but then we don’t actually put them gender equality, consent and sexual in Bangkok, Thailand. He still remembers the camaraderie. in positions of decision-making or rights,” he says, adding that even very “You could see that across South Asia, young people faced allow them to have a say in how an young students would benefit from obstacles in organizing themselves and accessing funding organization works, even if they are discussions around sensitive topics for this kind of work. Youth across the region also had similar the target group,” he says, pointing out like inappropriate touching. Often, challenges, particularly in how ‘culture’ was used in this vague that he was grateful to the opportunity the most potent tool in their arsenal way to justify withholding CSE for young people.” given to him to drive social change. proved to be the facts.

The experience proved key, and years later it would lead Senel However, talking about CSE with a “When we shared the to accept the job as a Manager of Youth Programmes at broader audience always highlighted data about the reality of FPA. Aside from the trainings he helped conduct, his second for Senel how misunderstood the responsibility was focusing on strengthening their Youth topic was. teenage pregnancies and Technical Advisory Committee, which was made up 10 to 20 the prevalence of unsafe young people who were brought together to inform the work of “People always seemed to assume abortions, a lot of people the organization and even advise their staff. Despite challenges that it was about how to have sex. would be quite surprised,” in execution, it is still a structure that Senel admires. We had to explain that we were Senel remembers, adding that when paired with corresponding data on how providing CSE was actually Early photo of sexuality education programmes conducted in Sri Lanka beneficial, it could change attitudes. of Economics and Political Science as a Chevening Scholar. More recently, he co-authored a Senel shares his belief that There were examples from other His interests have expanded to encompass meaningful civic book titled ‘A Montage of Sexuality this ‘right to information’ is countries that demonstrated and political participation of youth through initiatives like in Sri Lanka’, which was published by conclusively that offering young Hashtag Generation, which he co-founded. UNFPA and the Sri Lanka College of a fundamental one for all people CSE did not increase early Community Physicians in 2018. citizens. sexual activity or STI/HIV infection Run by a group of young tech-savvy, Sri Lankan volunteers, rates as people who are against CSE Hashtag Generation advocates for meaningful civic and For this unique publication, Senel “In a democracy, citizens should have feared – in fact, quite the opposite. political participation of youth, especially young women interviewed a wide range of people access to information that allows and youth from minority groups. Their projects include ‘We with differing experiences including them to make decisions about their Along the way, Senel realized Govern Sri Lanka’, which ran over three years and trained transgender individuals, sex workers, country and community but also their that adults are sometimes a group of 120 women from across the country who were women who had been subject to bodies,” he says, explaining that when unaware about the rights interested in contesting for local government elections. female genital mutilation, and young it comes to CSE the discourse tends “We’ve used our social media platforms to raise awareness women who had become pregnant to focus either on protecting young and choices they can make, on issues such as Muslim personal law reform and rights as teenagers. His features were people from sexually transmitted relating to their bodies. of Sri Lankans with diverse sexual orientations and gender complemented by medical insights infections or on preventing unintended “We realised that for some identities and rights of persons with disabilities,” says Senel. from doctors at the Sri Lanka College pregnancies. teachers and principals, they of Community Physicians. It’s In 2015, Senel was one of a group of ‘Social Media Fellows’, something that Senel is particularly “While all of these are very important, were learning about a few an initiative by UNFPA, to produce and introduce digital proud of. I think we need CSE for reasons much of these issues for the first content on sexual and reproductive health and rights issues. beyond those that are ‘preventative’ time as well. We shouldn’t In addition, both FPA and Hashtag Generation, are members His years of work in the field or ‘protectionist’,” says Senel, frankly. “The ability to understand have been surprised, they of the National Forum Against Gender-based violence that have taught him that the the UNFPA convenes. your body and to be able to make had gone through the same conversation around CSE decisions about it is a human right. By system we had been through.” In 2007, Senel received a medal from Queen Elizabeth II in needs to be anchored in a withholding this information we are recognition of his work on using social and new media tools to human rights perspective violating that right.” Senel would leave the FPA the next empower young people and women to meaningfully engage in rather than a strictly medical year to pursue his Master’s Degree in decision-making processes. Human Rights at the London School one. Referring to Sri Lanka’s Right to Information Act,

UNFPA works with the Government to implement comprehensive sexuality education through schools and community-based outreach © UNFPA Sri Lanka 74 75

CHAPTER 06

LOOKING AHEAD PROF. LAKSHMAN DISSANAYAKE After 50 years of continuous investments SENIOR PROFESSOR, DEPARTMENT OF in reproductive health in Sri Lanka, DEMOGRAPHY, UNIVERSITY OF COLOMBO what’s next?

2037.

DATA SHOULD NOT It’s a year that shows up often in Prof. Lakshman Dissanayake’s calculations. A senior JUST BE DISCUSSED Professor at the Department of Demography at the University of Colombo, Lakshman has dedicated a long career to studying Sri Lanka’s IN CLASSROOMS. population dynamics. For him, 2037 promises to be a milestone year because it’s when those above 60 years old will account for 22 percent AS DEMOGRAPHERS, of Sri Lanka’s population.

It reflects a profound change in the order of things, WE NEED TO LOOK AT especially when you consider that in 2012, this same group accounted for only 12.4 percent of the population – essentially, we are talking about a 103 percent increase HOW TO USE THE DATA in the number of people over 60 years of age, within just a short period of 25 years. FOR POPULATION 2037 is also the year that Lakshman says Sri Lanka’s first demographic dividend comes to an end. A demographic dividend only becomes possible when there is a decline in mortality and fertility rates, which usher in a period in which DYNAMICS. a country enjoys a high ratio of a working age population

in relation to smaller numbers of Lakshman knows that AN EVIDENCE-BASED APPROACH dependents such as the elderly demographic dividends and the very young. At its peak, the do not automatically Lakshman believes that the key to designing effective demographic dividend is a gift to policies will be in gathering data and evidence through a country as, it can drive growth bring benefits – careful research to inform policy-makers. In Medium-Term and expansion, and is a boon to the planning and successful Population Projection for Sri Lanka: 2012 to 2037, published economy – but only if we deliberately implementation are what by the UNFPA in 2016, Lakshman argues that projections make the most of it. make it real. “We need to should not only be used to inform planning in the public sector but also to underpin planning and marketing “This is how many countries have have appropriate policies strategies in the private sector. Furthermore, estimates of developed,” says Lakshman citing and services in place. For future population trends are also a crucial input into models examples such as Thailand, Hong instance, when you are of global environmental change and its impact. “Data should Kong, Korea and Malaysia that have considering a youth bulge, not just be discussed in classrooms,” he says, adding, “As made the most of having a large pool demographers, we need to look at how to use the data for of young workers. then we need to be thinking population dynamics.” about reproductive health Sri Lanka has long been considered issues,” he says, adding And the numbers can be revealing. one of the success stories in human that as the population development, leading its peers in the Mortality in Sri Lanka has declined region across a range of indicators. ages, the pressure points Early investments in health and shift, requiring a different substantially over the past decades. In the education have brought the country to approach and focus for health early 1920s, the average life expectancy at a point where significant reductions authorities. birth for men and women was 32.7 and 30.7 in infant mortality rates combined years, respectively. By 2002, those figures had with increases in life expectancy have Since advances in sexual and meant Sri Lankans are living longer, increased to 68.8 years for males and 77.2 reproductive healthcare have played healthier lives. These achievements years for females. The projected figures show such a critical role in Sri Lanka’s gains have influenced Sri Lanka’s so far, the country must look to how that male life expectancy is expected to reach demographic cycle. it can maintain these investments, 72.3 years while female life expectancy will be but also address gaps in reproductive What happens when Sri Lanka’s 82.5 years by 2026. health to ensure Sri Lanka is prepared population pyramid shifts, and more for the future. Lakshman is confident that Sri Lankans will enjoy people hit the age at which they would increasingly longer lifespans. “We are going to see typically retire? In this context, Sri Lanka could centenarians and super-centenarians in Sri Lanka,” he says. once again consider an innovative “If people retire at 65 years old, then we are asking them A CRITICAL TRANSITION approach. One example might be to spend 30, even forty years, outside of the labour force.” to take the current maternal and It doesn’t make sense when you consider that many will It is clear this transition will bring with childcare system and the cadre of remain physically and mentally fit well past the threshold of it specific challenges, particularly midwives who support it. Lakshman retirement. around healthcare. An ageing suggests creating a similar group of population presents significant social trained grassroots health workers protection challenges for vulnerable who can visit senior citizens in their groups, particularly low-income homes, check their blood pressure families supporting the elderly. In Sri and provide other basic health care Lanka, the number of female-headed needs. households has also increased in recent decades as has the number of However, developing such strategies people with disabilities, each of whom will require that we first understand face their own particular challenges. the challenges.

A SILVER ECONOMY enabling women to enter the OPENING A WINDOW OF labour force, and one that OPPORTUNITY Lakshman is over 65 himself, and it gives him a unique allows families to devote perspective. He stepped down as the Vice Chancellor of more resources to each child, UNFPA has long promoted additional the University of Colombo when it came time for him to investments in health and gender retire, but he is far from ready to quit work. Like many in thereby improving family equity, which are needed for Sri Lanka his generation, Lakshman has first-hand knowledge of how nutrition, education levels to open a window of opportunity. As advances in healthcare and education have ensured people and living standards. long-standing development partners can be genuinely productive for years after the time that of the Government of Sri Lanka, society would normally expect them to withdraw. In this context, Lakshman is Lakshman notes that UNFPA has also concerned about teenage invested in issues such as addressing There is real potential here – what Lakshman likes to call the pregnancies, which have been preventable maternal deaths and the ‘second demographic dividend’. “The current labour force associated with adverse health rising levels of teenage pregnancies, are the people who we will see going into old age, in to that outcomes during pregnancy and providing reproductive healthcare second demographic dividend,” he explains, adding that childbirth and can prevent young girls for women beyond 49 years of age, herein lies the potential for a silver economy. This economy from realising their full potential. and tackling inequities in access to will have to rely on elderly employees and be responsive reproductive health. to their needs. When people ask how the young will have On the other end of the spectrum, the access to opportunities in such a context, Lakshman is number of women over 50 years of Such efforts will prove critical as the forced to point out the hard reality that the number of age is also expected to increase. In country looks to a future in which a younger cohorts will have decreased – we simply won’t have 2012, that number was 2.6 million, healthy labour force could be one of enough young people to fulfil the demands of the market. but by 2036, it will nearly double to 4.4 Sri Lanka’s most significant assets, million. Simultaneously, women are providing the foundation and creating For Lakshman, it makes sense in such a situation to likely to live longer. the opportunities to break the cycles question making people redundant too soon when we of poverty and inequality. should instead be reconsidering when we retire and how we “This means that Sri Lankan women define ageing. One way to tap into this group will be for the will live 30 years beyond their fertile For his part, Lakshman is government and the private sector to ensure they have the age at least,” says Lakshman, adding right macroeconomic policies in place. “We have to improve generally optimistic about that in response, reproductive the health, and productivity of this generation, and we also what’s to come. “I have healthcare needs to now include have to improve the capacity of these people to save, so that programmes to support the needs of looked at every aspect of by the time they reach retirement age they have a nest egg a growing number of menopausal and our population and I am not to fall back on.” post-menopausal women. “We are not actually worried about our even talking about these issues yet,” He holds Japan up as an example Sri Lanka could emulate. population dynamics,” he he says. Having identified the challenge facing them, the country says. “The fact is that we developed relevant insurance schemes and promoted an It is also essential to consider are going to age, whether elder and disabled-friendly environment. women in the effort to ensure we like it or not. We need to equitable development. The elderly understand that and prepare A GENDER PERSPECTIVE are a vulnerable group and tend to experience significant levels of to face it with a positive Meanwhile, Sri Lanka can do much to strengthen its current poverty. Within this cohort, elderly mind.” generation of young workers. In particular, Female Labour women are especially at risk. Force Participation has stagnated in recent years, and Sri Research has shown that old women Lanka could see real dividends by bringing its women into are more likely to be poorer than the workforce. old men, because more women will live longer and are more likely to be The choice of whether, when, and how many unemployed. children to have, has a critical role to play. In fact, family planning programmes are widely recognized as one of the most cost-effective health interventions, a critical step toward

CHAPTER 07

ACCELERATING THE PROMISE

In 1994, when 179 governments gathered in Cairo for the landmark International Conference on Population and Development (ICPD), Sri Lanka was one of them.

As the Head of the Sri Lanka Delegation, Bradman Weerakoon, would contribute to the promise of the ICPD that would shift the global paradigm for population and development. The promise would be based on a plan for sustainable development, that was grounded in individual rights and choices and the achievement of sexual and reproductive health for all. It was embodied in a Programme of Action, that not only re-energized the global reproductive rights movement, but also positioned UNFPA as the movement’s custodian.

Specifically, it called for all people to have access to comprehensive reproductive health care, including voluntary family planning, safe pregnancy and childbirth services, and the prevention and treatment of sexually transmitted infections.

It also recognized that reproductive health and women’s empowerment are intertwined, and that both are necessary for the advancement of society.

The promise proved its relevance year on year, and 20 years later, Madusha Dissanayake would represent Sri Lanka at the iconic conference, when ICPD+20 marked a critical anniversary.

Today, 25 years on, Bradman and Madusha, meet and discuss the road that led to where Sri Lanka is today, and the challenges that lay ahead in accelerating the promise.

In the years leading up to the ICPD in This is an organization Cairo, Bradman had become one of Sri which expresses itself most Lanka’s most respected civil servants. Famous as a man who had served in effectively by bringing to bear nine successive governments of a certain moral force, the Sri Lanka, he had first entered civil collective moral force and service as a 22-year-old in 1952. decency of human beings.” D. S. Senanayake, Ceylon’s first Prime Meanwhile, Bradman continued to Minister, would be laid to rest that year, serve his country. A degree in sociology and his son Dudley would step into had left him with an enduring interest his father’s shoes, only to resign the in population issues. At the time, it next year. In October 1953, Sir John was believed that family planning and Kotelawala was appointed the Prime controlled population growth was the Minister. His reign would last three key to ensuring a prosperous future years, by when Sri Lanka would join for Sri Lanka. In the 1970s, as the the United Nations. Government Agent in Galle, Ampara and Kalutara, Bradman would see to the LAYING A FOUNDATION establishing of the first family planning clinics in the area. “John Kotelawala was very open and most generous in his views. He believed Sri Lanka’s approach was never one of in women’s equality and there were no making family planning compulsory distinctions in his mind. He believed in but rather of ensuring people had human rights for all. Ignorance was a access to the relevant information and crime for him,” Bradman recalls today. contraceptives they needed. “None of our governments ever imposed this In those years, Sri Lanka’s fledgling choice on families, we never had a one- democracy had begun to invest child policy; people took to it of their increasingly in education and health. own volition,” he says. In other words, they were laying the foundation for the future. Humming under his breath, he recalls a jingle that would run on the radio at Speaking at the United the time and captured the advice the Nations General Assembly government offered: “Not too many, not too soon, not too early, not too late…” in 1956, his successor Prime It encapsulated the advice to parents Minister S. W. R. D. at the time about the size of a family, Bandaranaike told his and how to space out their children. All audience: “My country is a these years later, it is still catchy. small one, a weak one and In 1984, Bradman would take up a place (3rd from left) Then Prime Minister of Sri Lanka, S.W.R.D. Bandaranaike, at the a poor one, but I venture to at the International Planned Parenthood 11th UN General Assembly in 1956 at which Celyon delivered its first statement © UN Photo think that today, particularly Federation (IPPF). Formed in 1952 in in an organization such as India, IPPF had from its earliest years embraced the principle that women this, the service that a country would have the right to plan their A GLOBAL SHIFT It was a pivotal time in IPPF’s history. Funding from the United The IPPF was faced with a hard choice, Bradman’s conviction and commitment can render – that a member pregnancies and space their births. For States accounted for 25 percent of their budget, however, but Bradman and his colleagues came from a deep respect for a can render – is not to be Bradman, this posting would give him a In 1968, the IPPF successfully argued its case before the political developments soon put that into question. The knew compromise was out of the woman’s right to control her own body. measured alone by the size new perspective. world’s first International Conference on Human Rights that Reagan administration wanted to move from a focus on family question. They refused to back down, “It was simply a right that I thought Family Planning too was a human right. It was a foundation planning to advocating abstinence, infertility counselling, and and successfully secured alternative everybody should recognize.” of that country, its population, stone on which the UNFPA would build in the years to come. natural contraception. After 1986, the administration threw its sources of funding. For their pioneering its power or its strength. Now, as the Secretary General of IPPF, Bradman was in a full weight behind a “Superbill”, which would restrict funding to work, they received the United Nations Bradman would return to Sri Lanka, and position of great influence as the organization expanded into any clinics that refer for abortion, counsel for abortion or are Population Award in 1985. government service, when his stint with a global movement. closely overlapping fiscally or physically with abortion services. the IPPF ended in 1989. A few years 84 85

later, when he led the delegation to ICPD, it was with the hope health, and Bradman remembers In her book ‘An Agenda for in agreement that the conference radically from top-down approaches THE NEW ZEROES that they would break new ground in the conversation around participating in spirited debates that People: The UNFPA through transformed the views and perceptions of and centrally formulated sexual and reproductive health and rights. lasted till 4am in the morning. Against Three Decades’, Nafis Sadiq, thousands of policymakers and programme demographic goals, to those 20 years later, when Madusha (Madu) all odds it seemed, a consensus was Dissanayake, sat in the audience Sri Lanka was one of 179 countries in attendance. The reached on many vital issues. former Executive Director of managers. It shifted how population policies that respect rights and of ICPD+20 she saw these very conference had been marked by a number of highly publicized UNFPA and Bradman’s friend, and programmes would be formulated and choices of individuals and accomplishments encapsulated in controversies around reproductive rights and reproductive noted commentators were implemented in the future, marking a change couples. the testimonies of young people who health, notably around adolescent sexual and reproductive had been born in the intervening years. The conference also drove a deeper “This was likely the main difference understanding of how population between the first conferences and now was linked to development. It looked – there were so many young people at population dynamics such as and they were actively engaged in the migration, population growth, ageing, process at every level,” recalls Madu. and urbanization, and how countries would thrive only if these issues were Here was a generation focused factored into development plans, on ensuring the human rights and policies and programmes. Importantly, empowerment of women, and of Bradman saw support crystallize for society as a whole. It was a generation their argument that gender equality that understood that the first and and the empowerment of women biggest step would be to give women must be pursued not just in principle the information and agency they but also simply because it would needed to decide what would happen improve quality of life for everyone, to their own bodies. including men and boys. However, while the ICPD had delivered

A WOMAN’S RIGHT TO CONTROL HER OWN BODY, WAS SIMPLY A RIGHT THAT I THOUGHT EVERYBODY SHOULD RECOGNIZE. BRADMAN WEERAKOON HEAD OF SRI LANKA DELEGATION TO ICPD IN 1994

179 governments meet in Cairo to produce a Programme of Action that will become a blueprint for global population policy © UN Photo 86 87

on many promises, there was still a long way to go. “Our goal accomplished was the result of key, and there can be no development now is zero maternal mortality, zero unmet need for family progressive changes, rather than any without a corresponding agenda that planning, and zero incidence of gender-based violence,” says single moment.” Madu agrees, pointing protects the rights of women and Madu. Drawing from years of experience working in sexual and to the provision of free education and young people, including their rights to reproductive health at the Family Planning Association – where healthcare as one of Sri Lanka’s great education, to sexual and reproductive she was hired by a panel that included Bradman himself –and strengths. Looking back on recent health, and to freedom from now at the UNFPA where she is Assistant Representative in Sri history, it is possible to trace how this discrimination and violence. Lanka, she sees these three goals as inextricably intertwined. contributed to a population that was healthier and better educated than that “I feel that we have strong policies Reflecting on Sri Lanka’s trajectory, Madu could see the shift of many other countries in the region. in place, and that these have been between focusing on health-centric issues such as reducing enhanced over time,” says Madu, “but maternal mortality, to an outlook where the emphasis was on “We have done a lot in many areas,” for us the focus needs to be on creating ensuring that every pregnancy was wanted. says Bradman, reflectively. “We have systems that are resilient and are not accomplished a lot by being willing to anchored solely in individuals, resulting “Sri Lanka put in a lot of effort to develop our network and build alliances that are in systems collapsing when someone both lateral and vertical. I think that has leaves.” health sector. If you look at the period from really helped us spread the message. the 60s to the 90s those four decades were UNFPA has done a lot in this regard.” In the end, Madu feels that Sri Lanka a golden period. We saw how certain bold However, he is as keenly aware as must look forward but continue to be decisions were taken and based on a clear she is that the road stretches ahead. informed by the many successes of its For him it’s essential that Sri Lanka past, and the rare courage that people direction,” Madu reflects. “There was a certain continue to build on its achievements. like Bradman brought to their work. strong sense of identity that said, this is where “Let’s stop spending so much time on “It was always more than a job for we are, this is who we are and this is where we what is working, but look now to what you. It was your life’s work,” she says, want to reach.” gaps remain.” For Bradman, those gaps with much respect to Bradman. “This are evident. He feels like some of generation too must learn how to be Sri Lanka’s thorniest challenges now lie honest and fearless in our convictions. When it came time to set The Millennium Development Goals in empowering youth and addressing This is how we can accelerate (MDGs), which laid out global aims and targets from year pernicious gender-based violence. 2000 for the next 15 years, Madu was among those who the promise.” For them both, young people are the noted with concern that the focus on reproductive health was quite inadequate. But by the time of 2014, and the ICPD+20 had rolled out, the global community was looking to the new Sustainable Development Goals (SDGs). The SDG target of universal health access emphasised sexual and reproductive health-care services, including for family planning, information and education, and the integration of reproductive health into OUR GOAL NOW IS ZERO national strategies and programmes. In recent years, sexual and reproductive health has been consistently included in key indicators in global health policymaking and providing access to these services is now seen increasingly as a human right. MATERNAL MORTALITY, In some ways it feels like a return to those electric days in Cairo, where sexual and reproductive health had a place of prominence on the global human rights agenda. ZERO UNMET NEED FOR THE RACE YET TO BE RUN FAMILY PLANNING, AND This long conversation unfolded in a quiet room in Colombo where Madu and Bradman sat side by side. For the two, now old friends as well as old colleagues, this is a moment where Sri Lanka must reaffirm its commitment to certain ZERO GENDER-BASED vital principles. Bradman at 89 is sharp yet frail, and asks with interest of the developments in the wider world. VIOLENCE. Looking at Madu, Bradman says: “In hindsight, what we MADUSHA DISSANAYAKE MEMBER OF SRI LANKA DELEGATION TO ICPD+20 IN 2014 AND CURRENT ASSISTANT REPRESENTATIVE, UNFPA SRI LANKA Bradman Weerakoon and Madusha Dissanayake discuss the road that led to where Sri Lanka is today © UNFPA Sri Lanka This report was developed under the auspices of the UNFPA in Sri Lanka.

EDITORIAL TEAM ACKNOWLEDGEMENTS

Concept UNFPA expresses sincere gratitude to the following UNFPA Sri Lanka Communications women for sharing glimpses of their lives for this publication Writer Anutharsi Linganathan Smriti Daniel Esha Kapparage Razni Razick Contributors Sandamali Silva Ajith Liyanage Sugunakumary Ranjith Avindi Perera Niluka Sandamali UNFPA is grateful to the following individuals for Randima Jayasinghe sharing their insights and views on sexual and Udani Udya reproductive health in Sri Lanka Ushanthy Gowthaman Bradman Weerakoon Harshalal Seneviratne Layout & Design Lakshman Dissanayake Abdul Basith Lakshmen Senanayake Madusha Dissanayake PHOTOGRAPHY Pramilla Senanayake Rizvina De Alwis Feature stories Senel Wanniarachchi © UNFPA Sri Lanka / Shehan Obeysekera

Timeline & Chapters © Family Planning Association, Sri Lanka © UN Photo © UNFPA Sri Lanka / Christian Hutter © UNFPA Sri Lanka / Munira Mutaher © UNFPA Sri Lanka / Ruvin De Silva

This publication is under copyright and all rights reserved. Short excerpts may be reproduced without authorization on condition that the source is indicated. For right of reproduction or translation, please contact the United Nations Population Fund in Sri Lanka.

This publication is available online at: http://srilanka.unfpa.org

ISBN 978-955-8375-15-0