Polygamists and Sinful IUDs: Family Planning in Zambia

19 May 2014

“Every morning she used to shampoo my locks…first we were dating, now we are mating, penetrating…” went the lyrics to the African rap/reggae song that so appropriately welcomed me to Zambia where I would be working in family planning.   After over 35-hours of travel time, I had finally made it to Zambia and was on the way to my hotel at last.  I had literally traveled to the opposite side of the globe from the middle of the Pacific Ocean to southern Africa.  When the chauffeur to the hotel asked where I was from, and I answered, “Hawaii,” she was actually surprised to hear that that was an island.  She asked if we had a Mediterranean climate there.  Clearly she knew about as much about the geography of my continent as I knew about hers.

I had about 24-hours to try to recover from serious jetlag before we had to report to work Monday morning.  I was to be working with another OBGYN from Seattle and a physician from Madagascar to perform a quality assurance audit of the Society of Family Health program in Zambia.  Together, we would spend the next two-weeks traveling to different regions of Zambia on behalf of a global NGO called Population Services International (PSI).  We would observe the local practices related to intrauterine devices and contraceptive implants to be sure they were performing these services up to code. 

A driver picked us up on Monday morning.  Leaving the hotel, we literally made two left turns and a right before we arrived at the Society of Family Health (SFH) headquarters.  When we got out of the car, we realized that SFH was literally across the street from the back of the hotel.  “We did not want to make you walk on your first day!” they explained.

A bowl of both female and male condoms caught my eye as I walked in the front door.  This was the first time I had ever seen a female condom since they model they showed in high school sex ed class; let’s just say, its not a popular birth control method in the US. 

We received a very warm, friendly greeting from the staff at SFH in an office building that was as nice as any I had been to in the US.  We spent the morning being debriefed by the leaders of the reproductive health program, which consisted primarily of four Zambian women, two of whom used to be practicing pediatricians, another who was a midwife, and the fourth who had more of a public health background.  I was happy to see this group of smart, progressive women running such a worthwhile program.  They were all exceedingly professional, polite, energetic, and articulate.

During the morning presentation, we learned that the organization, in place since 1992, focuses on HIV care, male circumcision, malaria net distribution, chlorine tablets for water purification, and reproductive health and family planning.  The organization worked to train retired midwives who work out of government-funded clinics to place implants and IUDs free of charge.

Zambia is healthier than a lot of African countries, but still not anywhere near the status of a developed country; about 14% of people have HIV, 591 out of 100,000 women die during or after childbirth, and the average woman has at least 6-children.  They said it was not uncommon to see a woman in her late 20’s who had already had 8 or 9 children.  Clearly this highlights the need for family planning options and sadly, les than 1% of women were option for long-term contraceptives like intrauterine devices or implants.  This group is working to change this by training more nurses and midwives to place them and have what they call “mobilizers” go out into the community and talk about birth control.  The group here feels that the tide is turning with funds coming in from the Gates Foundation and political support from the first lady of Zambia who happens to be an OBGYN.

I have heard many a myth and misconception about the contraceptive devices in the US, but they were even more interesting and outlandish in Zambia.  The reasons women said they avoided IUDs and implants included, “it causes cancer,” “it could move and travel to my heart,” “it’s a sin to have a foreign object in your body when you die, who will take it out of I die,” and then some men said, “we want our women to have their monthly periods to clean them out.”  Many women also want to have a lot of children.   Having many children is seen as a sign of wealth.  Polygamy is quite common in Zambia so women contest to be the wife with the most children; they say it offers them polygamist marriage security. 

After our debriefing, we spent the remainder of the day sorting through the documents that the SFH headquarters uses to train, audit and oversee its many sites all over the country.  It was as a good overview to get an idea of what we would be seeing and experiencing as we traveled to four different provinces in Zambia to observe and audit the contraceptive practices over the coming two weeks.