Approaching Health Ethics of Reproduction in the female : the example of Tunisia

1. ApproachingHealth Ethics of Reproduction in the female :the example of Tunisia Pr. Majed ZEMNI Cairo 7-8 December 2011 UNESCO RegionalConference on « Current Challenges in Women’sHealth Care and MedicalResearch »

2. Introduction • The reproductive health is an important component of well physical, mental and social being. • Tunisia has undergone significantchanges in reproductive health of women in several areas.

3. Age for marriage The statutory age for marriage is limited to 17 years for the young girl on the condition of their consent.Before20 years, marriage is subject to the consent of the tutor and mother.This joint authority theoretically allows  to avoid the risk of a unilateral decision,but marriage by choice of the tutor is not uncommon.

5. Sanctions

6. Prenatal monitoring • Coverage rate of prenatal visit increased from 54 % in 1984 to 84.5 % in 1997. • Essential concept developed and integrated in family planning and more comprehensive approach to reproductive health.

7. Supervision of pregnancy  There is a protocol for monitoring pregnancy proposed by the CaisseNationaled'AssuranceMaladie (CNAM). The annual ceiling ambulatorvists :100 dinars over in case of pregnancy.  Ability to support the cost of delivery in the private sector.

9. Pre-and post-natal vacation • Motherhood is recognized as essential social function. • No prenatal vacation • Public sector :women received maternity leave on full pay for 02 months and the possibility of its extension by 04 monthsleave on half-pay. • Private sector : women received maternity leave of 30 days with 2/3 of salary and the possibility of 30 days extension on medical reason. • Costs supported by the CNAM.

10. Pregnantimprisonedwomen • Law n°58-2008, related to the Pregnant or nursing imprisonedwomen • Women prisoners, pregnant or nursing are, during the period of pregnancy and lactation, incarcerated in a suitable space, arranged for this purpose with the medical, psychological and social mother and child. • Custody  is provided by supervisors in civilian clothes.

11. Medicallyassistedprocreation • Law of August 7th, 2001 on of reproductive medicine. • Opinion n°1, 1996 of Tunisian National Committee of Medical Ethics. • MAP is a Growing business in Tunisia.Activity supervised by legal text.Guaranteed to be conducted by competent specialists.Be done in Private or public sector.

12. First ethicalrequirement: competence • Respect of the rules by specialists • Improvingtechnics • Healthsafety • The law took into account the context of our society (married couple,age of mariage and procreation, gametedonor and surrogate motherhood are banned).

13. Information and consent ismandatory • Of the couple • Individual interviews • Previoustreatment • Scientificevolution • SuccessRate • Severalattempts • Possible effects on health of the mother and the futurnewborn • Written consent of the couple is compulsory.

14. The Formular of written consent

15. Equity • The resourcesallocated • Free access

16. AMP isSupportedby the CNAM but with conditions • Womenunder 40 years • No living children • Three attempts : some of the location (public or private) and whatever the technical Advantages : • Promotes reproductive rights even if the couple's resources are limitedmeasure of social • Equality (couple underprivileged)

17. But ethicalproblems • For the law "of reproductive age“ • Womenunder 40 years Menopause 49 years, Life expectancy at 74 years • Long attemptsintervals • Long Waiting time in AMP centers • Does not cover the full cost.

18. HIV serodifferent couple • The law provides the couple with HIV to have access to AMP • Technical caution

19. HIV serodifferent couple

20. Tunisian Code of MedicalEthicsobstructed labor Decree N° 93-1155 of 17 May 1993 concerning the Code of Medical Ethics. Article 41 : During prolonged or obstructed labor, the physician should consider himself the only judge of the respective interests of the mother and child without being influenced by family considerations.

21. Maternalmortality • Defined as the death related to pregnancy of a woman from conception to the 42nd day after birth. • Good indicator of quality of care especially since these deaths are deemed to bepreventable. • Mortality rate fell from 68.9 per 100000 births in 1994 to 44 in 2011.Objectif : 18/100 miles in 2015.

22. Chalenges • A strong regional disparities between coastal regions of the East with 51.6 per one hundred thousand live births against 99.4 for the West • The areas most affected are the central east and south. • Cultural problem : early marriage and pregnancy, especially repeated and closely spaced ones (declininginTunisia): average age of marriage rose from 19.4 years in 1966 to 27 in 1994.

23. Abortion • Is not a contraceptive and family planning way: be considered as an ultimate solution by the women and especially the doctor (The close of conscience of the physician). • Article 40 of Tunisiancode of ethics: It can not be performed an abortion except in the cases and conditions provided by law.

24. Conditions • The law punishes illegal abortion or non-medical assisted abortion in order to preserve the mother’s health. • Conditions : - 03first months of pregnancy (12 weeks) - Public hospital or a private clinic  - Physician practicing legalytheir profession • The law gives freedom to the physician became aware of illegal abortion to denunciation or not of the illegal abortion (to protect the health of the mother and encourage her to visit).

25. Conclusion • Tunisia has made progress in the services offering to support health needs of women • Several regulations consolidate and protect the rights of women in reproductive health • Chalenge : interregional inequality between the different levels of care.