MPH | Cabo Delgado, Mozambique | May – August 2014
“If she wants to keep a secret, I tell her go, talk to your husband and come back.”
I work on a program in rural Mozambique to train and equip community health workers to provide a method of contraceptive – Depo, or “the shot” – so women do not have to travel to distant, crowded, poorly stocked health facilities to prevent unwanted pregnancies. We know that the majority of poor, rural women in this region prefer this method, and it has many benefits. It is female-controlled (unlike condoms which require partner cooperation), it is inconspicuous (not requiring a daily pill or keeping those commodities lying around the house for anyone to find), and one shot lasts for 3 months. These benefits translate to an opportunity for women who live in patriarchal, conservative, pronatalist communities to space births covertly if need be.
During an interview with the community health workers on this project I was told that most women get the shot in the company of their husbands. While this is terrific, what happens when a woman is not with her husband? What happens if she asks you to keep the 3-month reprieve from conception a secret? One health worker told me, “If she wants to keep a secret, I tell her go, talk to your husband and come back.” Most others agreed.
Covert use is clearly not the ideal situation. In an egalitarian society, between equal partners in a relationship, joint decision-making is the ideal way for couples to plan their families. But in a context where men make all household decisions, but women face the real risk of death in childbirth, women should have the option to mitigate this risk, completely or even periodically, if they choose.
What astounded me about this response was the source. These health workers are traditional birth attendants, unskilled providers who facilitate over half of the births in rural Africa. They are the trusted guardians of the labor and delivery process in millions of African homes each year. And with a maternal mortality ratio of 480 maternal deaths per 100,000 live births in Mozambique (compared to Mexico where the MMR is 49, the US where it is 28, or the UK where the MMR is 8 deaths per 100,000 births), these health workers have certainly seen the tragic loss of life which can result from pregnancy. Surely these health workers, these birth attendants, of anyone, would support a woman’s desire not to bear that risk if she prefers to avoid it? Unfortunately, even they don’t without husband approval.
The health workers’ reluctance to provide covert contraception prompts recommendations for the project I work on, and for family planning programs in Africa generally. But more than that, it points to the persistent entrenchment of gender-based inequities that have life-threatening ramifications for women and girls. It highlights that we cannot talk about family planning, or any other health issue for that matter, without talking about gender disparities. It underscores that considerations about gender in global programs cannot be relegated to a secondary issue with miniscule budget and sidelined staff, but rather are central to improving health and development outcomes. If the key to development of the global south is through empowerment of women and girls (as many international aid agencies agree, including The Clinton and Gates Foundations, USAID, and many others), surely gender empowerment through and by family planning programs is the issue. Without options for spacing or limiting births, women’s opportunities to participate in education or income-generating activities are severely curtailed if not dashed entirely. When families are too large, children receive less food, education, and attention. Girls suffer disproportionately from this phenomenon. And the vicious cycle continues.
After talking to the health worker who told me that women need to come with their husbands to get the shot, I had the pleasure of speaking with one of her clients, a woman in her 30s with nine living children and four who had passed away. I asked her about the challenges she faced accessing family planning, and she told me that her biggest obstacle was her husband. Since taking Depo, she had experienced continuous spotting, a common side effect with this method. Her husband did not like the spotting. He wanted her to stop taking Depo. “Do you want to stop taking Depo?” I asked. No, she told me, she wanted to rest. She did not want to have any more children. “What will you do if he forbids you from taking it?” I asked. She told me she would go to the traditional birth attendant and get her shot in secret.
I told her that with a couple more shots the spotting will likely abate. I did not tell her that covert use was not an option for her, even if the spotting does stop, since her traditional birth attendant will not allow her to get the shot without her husband’s consent. I think about her every day.
Family planning must be available to all women, in every situation, supportive or not. It is critical that we consider this issue within a human rights framework at the grassroots and program levels when we advocate to policy-makers, train providers, and educate communities. Change is slow. For the time being, some women and girls do not have the support of their partners or the decision-making power to make unilateral choices about contraception. These women must be enabled to make reproductive health choices for themselves. We must create opportunities to make it clear to policy-makers, healthcare providers, and communities that while it is ideal for couples to decide, ultimately, contraception is a woman’s right.
Cassandra is also a University of California Human Rights Fellow, sponsored by the Human Rights Center at the UC Berkeley School of Law