It aint easy being a woman, especially in Africa...

25 March 2014

The concept of being “born” is a crazy one; one moment you don’t exist, the next moment, boom, there you are.  The clock starts, experiences happen, memories form.  We have no control over by whom or how we are born, it just happens to us.  I didn’t choose to be born into a family with kind parents in a developed country, but I sure feel fortunate I was.  As we travel around Africa and I interact with my peers here, I can’t stop thinking how lucky I am.  At the same time, I feel kindred to these women; I could be her, she could be me. 

Life is harder for women; some may argue that, but I believe that is a fact.  As women, the world over, we subject our bodies to the risks of pregnancy and childbirth, we are more likely to be the victims of sexual and domestic violence, we are sexually objectified, we earn less money than our male counterparts, and even in developed countries, we must endure sexual oppression.  All of us women of the developed world can share stories of our experiences with gender-based harassment, abuse, discrimination and oppression, but our sufferings most likely pale in comparison to the sufferings of our “sisters” in the developing world.

Let me enlighten you with the facts about life as a woman in Zambia.  She starts off with fewer days on her clock than we do, with the projected life expectancy for a Zambian woman being 58 years (compared to 81 in the US).  She might consider herself lucky to even make it past the age of 5, since 89 out of 1,000 Zambian babies won’t make it that long (compared to 7 of 1000 US ones).  She will probably start bearing children at a young age since 125 of 100,000 live births are to women aged 15 to 24 (compared to 31/100,000 in the US).  She will have a lot of babies, on average, nearly six.  Not all of those babies will make it through pregnancy, as Zambian infant mortality is 56 of 1000 live births (versus 6 of 1000 in the US).  There are also fairly good odds that she may not survive pregnancy or childbirth either since 8% of women of reproductive age will die during childbirth (compared to 0.8% in Canada and 1.5% in the US).  Sometime during her life, she very well may be contract HIV, with prevalence in Zambia of 14%.

Zambian women might actually feel fortunate when they compare themselves to some of their neighbors, though.  The situation seems to be particularly poor in Chad and Sierra Leone.  Chad has the highest adolescent fertility rate at 152 of 100,00 births and the second worst maternal mortality at 980 per 100,000 childbirths, which translates into this staggering fact:  29% of women of reproductive age will die during childbirth. One out of three!  Sierra Leone has the highest maternal and infant mortality rates in the world at 1100 per 100,000 births and 117 per 1000, respectively.  A few other countries in Africa had some shocking statistics as well, like the 20% prevalence of HIV in women aged 15 to 24 in Swaziland.  Then there is the 39% female literacy rate in Mali (compared to 56% in their male counterparts).  Finally, there is also the fact that 44% of girls aged 7 to 14 are employed and working in Burkina Faso and Guinea. 

 

The many reasons I listed are essentially why I am here in Zambia right now.  Providing contraception and educating women about family planning saves lives of women and children.  That is a fact.  With an unmet need for family planning quoted at 27% in Zambia (compared to 7% in the US), there is still room for improvement.  That is why groups like PSI, the NGO with whom I am working, have helped to establish Family Planning programs in Zambia and similar countries.  It is not as simple as merely teaching the local providers about contraception and providing the birth control methods though.  There are many barriers to overcome here that we simply do not deal with in the developed world and many of these barriers are just inherent to being a woman in Africa.

 

The first barrier is education and socioeconomics.  The women that I have seen in the clinics here are not a privileged and educated bunch.  In 1998, it was estimated that 63% of Zambians were living below the poverty line, making less than ONE DOLLAR a day.  This number has surely improved since then, but I hope it illustrates the kind of poverty I am talking about here.  Many of the women that I have seen interviewed seem to have made it about halfway through school, maybe to grade 7.  One woman said she never went at all.

There are a whole slew of contraceptive myths we have encountered during our trip which, to me, also highlight the lack of education these women have:  “the implant can move from the arm to the heart and pierce it,” “IUDs cause cancer,” “if the man’s penis is very long, can it move the IUD out of the womb.”  Half of the work that I have been involved with here is focused on educating women, dispelling myths, increasing awareness, and even identifying women in the community that spread rumors against contraception. 

Transportation, or lack thereof, is another huge barrier.  Driving down the roads, we see hundreds of women on foot with babies strapped to their backs or fronts, maybe even simultaneously breastfeeding.  If they are lucky, they may have a bicycle for transportation, but it seems mostly men get the bikes.  Some rural areas may not have a clinic or hospital any closer than 15-km.  Although the majority of Zambians have mobile phones, the reception in these rural areas is unreliable.  All of these realities explain why only 42% of Zambian births are attended by skilled professionals.  This circles back to the maternal mortality again…

The women here do not have a lot of control over their lives.  The men largely dictate when and how many children they have.   I have heard a number of women say they don’t want any more children, but they must defer to their husbands.  The men get to have the final say about contraception and whether they can use it.  Many of the contraceptive counselors here sell the IUD to the patients by reminding them that it is a “secret method” that their husbands will not be able to tell they are using.  She can’t use the female condom for pregnancy and HIV prevention, because the man will think she is promiscuous and diseased instead of empowered.  In some groups, the women don’t even get to decide when they can wash or shave their genitals, as the husband must perform it.  If she were to wash or shave herself, it would lead him to believe she was unfaithful.  Many of the husbands even send the women to do the manual labor like farming or selling of produce, while they do the beer drinking.  They do it all while tending to a couple small children at the same time.

Domestic violence is clearly another major problem here based on the number of billboards and posters around the country making public service announcements.  Nearly every other woman who is interested in the contraceptive implant (in the arm) has asked, “If the man beats you and hurts your arm, can the implant move to the heart?”  Domestic violence is clearly all too common a worry on these women’s minds. 

During one of our clinic visits last week, the nurse asked the patient if she would mind letting us observe the insertion of her IUD.  She giggled a little at first, looking shy, but they said, “Yes, why not, they are my fellow sisters after all.”  When you have a rough day and feel like life can’t get worse, remember your sisters in Africa. 

(Statistics I listed came mainly from the World Health Organization but also the World Bank, most stats were from 2013)

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.