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

Emily with Girl Child Education program manager, Khadija, and head mentor, Habiba.

It’s 3 o’clock in the afternoon. School has been out for nearly an hour. Fifteen giggling teenage girls huddle outside a mud-brick structure near the center of the village. “Malama, malama (teacher, teacher),” several of the girls cry out. Malama puts a finger to her lips to silence the girls. We are speaking with the Sarki—the village head—who greeted my colleague and I when we entered the village several minutes earlier. “This program is important. Look at the girls’ excitement,” Malama translates the Sarki’s words. “He says we must go now, the girls need their time in that room.”

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 MSPH, Associate Specialist, Research Analyst | Western Region of Kenya

“…The woman just cried and said that she wanted to get an IUD…”

Over 50 women were sitting in line waiting to be seen by the doctors. And yet it was not that there were so many of them that caught my attention, but rather that all of them, without a single exception, were holding an infant. These women had left their homes bright and early to attend the Marie Stopes mobile Family Planning (FP) clinic. The clinic was a community center that had been converted by a traveling team of doctors into a FP clinic for the day.

Most of the women were in line to get an Implant inserted. When I asked why they had chosen an implant as their FP method they mentioned that they wanted a long term method. An IUD was not considered because they believed that the IUDs would travel through your body.

We then walked over to where doctors were performing tubal ligations. They had performed three female sterilizations so far and two more women were waiting for the procedure. One of the women waiting was crying. We were told that the woman who was crying had come in with her 3 week old baby and her husband, who announced that unless she got a tubal ligation she could not return home and left. The woman just cried and said that she wanted to get an IUD and not sterilized because she was scared of the tubal ligation procedure. When the counselors went to her they learned that she was holding her 11^th child and that she was only in her mid-thirties, making her a poor candidate for an IUD. Since she had tried the implant before and did not like it they recommended that she go through with the sterilization.

Since her concerns with sterilization were based on fear, I suggested that they have a woman who had just been sterilized that morning share her experience. It was when she spoke to her that we learned the real reason for why she did not want to be sterilized. It was not that she feared the procedure, but rather that her husband had a second wife. She explained that if she got sterilized, she would not be able to have any more of his children, which would put the younger wife at an advantage and with higher status. We were all speechless and out of counseling talking points to address her concern.  And yet, in an area where 23% of married women have a husband that has at least one other wife, hers was a very real concern. If her status in her home and community center around the number of children she has, then it’s clear how an operation that made her unable to have any more children would be devastating. And yet this woman had no real choice. And worst we had no options to offer. She could either get sterilized and stop being a “valued” woman or not have the procedure and be homeless and away from her children. In the end the medical staff convinced her into getting the sterilization out of concern for her health. But I couldn’t help but feel like she had been coerced by her husband and community and failed by us.

It is my hope that by the time that her baby girl is in need of FP services the social norms in this community will have changed to the point that she never has to face a similar choice in her future. Because it is clearly more than just about making FP services available, women need to be empowered.

The Western Region of Kenya has one of the highest fertility rates (TFR=5.6) in the country and over 27% of sexually active women there have an unmet need for contraceptives. The Packard Foundation is currently funding a project in this region that is being led by the African Population and Health Research Center, in collaboration with the Division of Reproductive Health, Ministry of Public Health. The other major partners funded under this grant are Family Health Options Kenya, Marie Stopes Kenya (which organized the mobile clinic I visited), and the Great Lakes University of Kisumu.

The long term goals of the project are to reduce unwanted and mistimed pregnancies, unsafe abortion, maternal morbidity and mortality, and the fertility rate, as well as to improve the general health status of the target communities by encouraging uptake of long term contraceptive methods, influencing men’s attitudes towards family planning, and influencing desired family size and fertility intentions among women and men.

MPH and Bixby Doctoral Fellow | Luanda Province, Angola |  Summer 2012

“…she had very little formal training in family planning, and none in health education…”

I spent the summer in Angola with my classmate Aidan, interviewing women about their decisions related to childbearing and contraception.  One of the broader goals of that project is to improve access to family planning to women in Luanda Province, an area where doctors and other highly skilled health providers are scarce and where community-based provision of family planning has great potential. While we were there, Aidan and I learned a lot about the important role that community-level health workers can play in delivering family planning counseling and services.

We were assisted by the field team of our local NGO partners, led by a nurse named Filomena. Filomena is a devout Christian and has been working as a family planning nurse for decades.  She sees access to family planning as an issue of public health and human rights, and she’s been a proud supporter of expanding access to these services in her country. On one of our first outings with Filomena, we attended a women’s meeting at a local church. The church group had asked Filomena to give a talk about the benefits of modern family planning and Aidan and I jumped at the chance to see her in action.

Filomena began her presentation in a way that seemed truly unique to me: she put the focus squarely on the group’s religious beliefs, emphasizing that there was no contradiction between those beliefs and modern family planning. She mentioned that, as wives, mothers, and members of their church, the women in the audience had an obligation to care for their families and look after one another, a task that could become impossible if they were faced with an unintended pregnancy.

After introducing family planning in this way, Filomena proceeded to give an informative and amusing presentation on modern family planning methods, even offering tips and stories from her own life. She handled potentially uncomfortable moments with humor and warmth, often playing up graphic or funny details to put the crowd at ease. It was obvious that Filomena was a pro – she knew her material inside and out, and she was great at encouraging questions and responding to them thoughtfully and honestly. When misconceptions arose – for example, when one woman expressed concern that the contraceptive implant was actually a “chip” designed to record her sexual activity for the government – Filomena managed to correct them firmly but respectfully.

Filomena’s performance seemed especially impressive to me when she told me that she had very little formal training in family planning, and none in health education. She simply thought of herself as someone who cared deeply about giving women the right to control whether and when they got pregnant. When the Angolan government started its official family program in the 1980s, she signed on enthusiastically, earning a basic level of training that allowed her to provide counseling and services related to family planning.  Although she’d initially hoped to gain more specialized training, Angola’s decades-long civil war and the lack of health and education infrastructure made it impossible to advance her knowledge formally. Her detailed, up-to-date understanding of family planning methods and her phenomenal skills as a public speaker were learned on the job, first as a government worker and then as an NGO employee, encouraging women one by one to use family planning to take control of their bodies and their lives.

Seeing Filomena’s presentation reminded me of how important community-based action is to the work that we do, especially in settings like Angola, where opportunities for women to interact with highly skilled health providers tend to be few and far between. Filomena’s ability to connect with her audience comes in large part from the fact that she’s a member of the communities in which she works. As a Christian, Angolan woman who has used modern family planning, Filomena is able to build relationships with these communities based on characteristics like their shared faith and to use those relationships as a way to connect women to the family planning services they need. Supporting these types of community-based efforts will be a crucial step for us as we work to expand access to these critical health services.

MPH | Tigray, Ethiopia | May-July 2012

“…Water was so scarce that one of her responsibilities…was to regulate when her troops could sip from their flasks…”

Global health fieldwork is often challenging. There are the inevitable language barriers and cultural differences – which become all the more important to consider when dealing with sensitive topics like reproductive health. Compounding the communication difficulties, poor infrastructure can sometimes make it difficult to accomplish even routine tasks. I often find these challenges exciting, but at times they can be discouraging.

And midway through my summer internship with the Bixby Center in Ethiopia, I was a bit discouraged. My fellow intern Kristina and I were spending three months in Tigray, a region in Northern Ethiopia, to support the same program of community-based distribution of the injectable contraceptive DMPA that Karen wrote about last month. Our tasks were to collect GPS points for the houses of the project’s community-based reproductive health agents (CBRHAs), refresh CBRHAs on the data collection protocols, and assess whether they had any needs that the program wasn’t meeting. We had postponed our work due to scheduling conflicts with local partners; we were falling behind.

After a week of waiting, we were able to hold an educational meeting with the CBRHAs in one of the project areas. The meetings were well attended and were useful for the participants, a heartening success.

Another treat came that afternoon, when we attended a traditional Ethiopian coffee ceremony at the house of a public health nurse who was involved with the project. The coffee ceremony is a true feast for the senses: the wafting smoke from roasting coffee beans, the dull thud of the mortar and pestle as the beans are ground, then the taste of the strong black coffee, the smell of tree-bark incense, and the crunch of popcorn and sweetness of orange slices that are served with the drink.

During the coffee ceremony we looked through our colleague’s old photographs, black and white images of people with big Afros and somber eyes. She told us that she had been a commander in the Tigrayan People’s Liberation Front, when the region was fighting against the Derg – the communist regime that ruled over Ethiopia in the 1970s and 80s. Her troops were stationed in a nearby desert. Water was so scarce that one of her responsibilities as a commander was to regulate when her troops could sip from their flasks, and when they had to wait, thirsty.

Kristina and I were floored, while our Ethiopian colleagues simply listened calmly. As the coffee ceremony continued, we heard many more stories about the sacrifices this nurse and her colleagues had made during the years of fighting. Her stories put all the challenges we had been experiencing into sharp perspective. The colleagues we were sitting with had all found the strength and the spirit to fight for a worthy cause in circumstances far more extreme than our current situation.

Once we were more attuned to this recent history of resistance, we began seeing it everywhere. One of the project villages is called Guroro, which means “Throat”, because of the many who were hanged there during the years of fighting. Now the village wears that past like a mantle, or perhaps a defiant warning to any who would try to threaten it. At one of our meetings, a CBRHA said she tells women that if they have concerns about using contraception, they should draw upon their strength as fighters and do what is best for their families. And – my favorite – one of the project villages is called Ayin Birkaken, which means “Never Give Up”.

I could end by saying that Kristina and I learned to “never give up” in global health work, and we redoubled our efforts as interns for the rest of the summer. While that’s true, it’s not the whole picture. The stories renewed my passion for global health work, in spite of the challenges. But even more, they gave me a new level of respect and admiration for the strength of my colleagues who live the reality of these challenges in ways that I can only begin to imagine. Poor roads might make it annoying for me to get to sites for monitoring and evaluation, but they also mean that women in that region may be less likely to travel to a health clinic for health care. Bureaucratic inefficiencies put us a few days behind schedule, but they can make it hard for people working in the public sector to retain their optimism and their passion. I may be outraged by the high mortality rates in developing countries, but they mean that the loved ones of our colleagues in these countries are more likely to die early. Our colleague’s experience as a resistance fighter is an extreme example of a broad phenomenon – the courage and the ability to rise up to the challenges that exist. I have an incredible respect for these colleagues. I simply bear witness to their strength.

I thank the Bixby center for providing me with this opportunity to contribute to a project I believe in, and to learn so much from the people involved. And I thank our colleagues for the coffee, the photographs and the stories.

MPH, Research Specialist | Axum, Tigray, Ethiopia | November 2012

“…participants were so excited to demonstrate their skills with recruiting clients and provide family planning counseling that we actually had to interrupt their role play to move on to the next activity…”

At the beginning of November, just as everyone in the US was starting to prepare for Thanksgiving, I returned to Ethiopia for a fourth time as part of our project to increase rural access to injectable contraceptives. While I made it back to California in time to celebrate the holiday with friends and family, the visit to our project made me even more mindful of all the opportunities and gifts for which I am thankful.

The journey to Ethiopia is never simple. And after three flights, I arrived in Axum, a small town in the Tigray region. There is a great deal of historical significance associated with Axum, including UNESCO World Heritage Site, but my colleagues and I were there to conduct a training of 100+ Community Based Reproductive Health Agents (CBRHAs), as part of our project to scale up community based distribution (CBD) of the injectable contraceptive depot medroxyprogesterone acetate (Depo Provera) in Tigray, Ethiopia. The goal of the training was to teach CBRHAs how to provide Depo Provera in their villages, where women often face challenges in receiving family planning services at health facilities, due to distance to facility, stock-outs and often privacy issues. By training CBRHAs to provide Depo Provera, we hope to reduce some of the barriers that women face and increase their access to Depo Provera, which is the modern method of choice among rural women in Ethiopia. In a previous pilot study, we had demonstrated that CBRHAs were safe, effective and acceptable distributors of Depo Provera. The focus now was to go beyond the pilot study and scale up the successful findings. We had already trained 137 CBRHAs in three districts. Those CBRHAs had gone on to provide 2540 injections of Depo Provera in their communities, a vast majority to women who were new to family planning or Depo Provera.

This was our second training since the project commenced a year prior and we were excited and nervous as we made final preparations. As with prior trainings, until the morning of the first day, it is impossible to know how many CBRHAs will in fact arrive for the training. Since they are widely-dispersed, often without formal means of communication, we are left wondering if our invitation to join the training was delivered. As always, I was amazed as they arrived, many from villages that required a full day of travel. In the end, we had 101 CBRHAs complete the 4 day training. There were several highlights to the training. We introduced more role play activities and the participants were so excited to demonstrate their skills with recruiting clients and provide family planning counseling that we actually had to interrupt their role play to move on to the next activity. We also invited high performers from the first training to share their experiences and give advice to the new trainees. As they shared their experiences with the participants, they also spoke about how the project positively impacted them and their community. During one of the afternoon breaks, the CBRHAs broke out into song and dance – an impromptu refresher. The energy of the groups was contagious and I couldn’t help but join the dancing and singing. I am sure I looked ridiculous, but at that moment, my smile and laughter were unstoppable.

As the CBRHAs left the training, beginning their journey back to their respective villages, carrying new blue bags with a supply of Depo Provera, I thought about how even though the training was a success, the work was far from done. In fact, we will train an additional 700 CBRHAs in the next two years. As I sat around the table with my family and friends at Thanksgiving, I also reflected on our work in Ethiopia. We are providing an important and necessary service to the women of Tigray, yet on Thanksgiving, I only thought about dancing in the circle with training participants and realized that they are also giving me a very important gift.