Approaching Health Ethics of Reproduction in the female :

the example of TunisiaPr. Majed ZEMNI

Cairo 7-8 December 2011

UNESCO Regional Conference on« Current Challenges in Women’s Health Care

and Medical Research »

Introduction The reproductive health is an important

component of well physical, mental and social being.

Tunisia has undergone significant  changes 

in reproductive health of women in several areas.

Age for marriage The statutory age for marriage is limited to

17 years for the young girl on the condition of their consent.Before 20 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.

Sanctions

Prenatal monitoringCoverage 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.

Supervision of pregnancy

There is a protocol for monitoring pregnancy  proposed by the Caisse

Nationale d'Assurance Maladie (CNAM).

The annual ceiling ambulator vists : 100 dinars over in case of pregnancy.

Ability to support the cost of delivery in the private sector.

Pre-and post-natal vacationMotherhood 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 months leave 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.

Pregnant imprisoned womenLaw n°58-2008, related to the Pregnant or

nursing imprisoned women 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.

Medically assisted procreation

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.

First ethical requirement : competence

Respect of the rules by specialistsImproving technicsHealth safetyThe law took into account the context of

our society (married couple, age of mariage and procreation, gamete donor and surrogate motherhood are banned).

Information and consent is mandatory 

Of the coupleIndividual interviewsPrevious treatmentScientific evolutionSuccess RateSeveral attemptsPossible effects on health of the mother and

the futur newbornWritten consent of the couple is compulsory.

The Formularof written consent

Equity

The resources allocated

Free access

AMP is Supported by the CNAM but with conditions 

Women under 40 yearsNo 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)

But ethical problemsFor the law "of reproductive age“Women under 40 years Menopause 49 years, Life expectancy at 74

years

Long attempts intervalsLong Waiting time in  AMP centersDoes not cover the full cost.

HIV serodifferent couple 

The law provides the couple with HIV to have access to AMP

Technical caution

HIV serodifferent couple 

Tunisian Code of Medical Ethics obstructed 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.

Maternal mortality

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 be preventable.

Mortality rate fell from 68.9 per 100000 births in 1994 to 44 in 2011.Objectif : 18/100 miles in 2015.

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 (declining inTunisia): average age of marriage rose from 19.4 years in 1966 to 27 in 1994.

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 Tunisian code of ethics: It can not be performed an abortion except in the cases and conditions provided by law.

Conditions The law punishes illegal abortion or non-

medical assisted abortion in order to preserve the mother’s health.

Conditions : - 03 first months of pregnancy (12 weeks)- Public hospital or a private clinic - Physician practicing legaly their 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).

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.