This is a relatively long two part posting… so tuck in for a nice read :)
A recent Demographic and Health Survey report for 20 countries throughout Asia, the Middle East, Africa, and Latin America states that on average, 34% of all pregnancies result in an unintended live birth or an induced abortion. In other words, 1/3 of pregnancies in this representative sample of low and middle income countries are unplanned and unwanted. Furthermore, one in three unintended births is a result of contraceptive failure, while more than half of induced abortions are a result of contraceptive failure. Its a two stage problem: there is serious unmet need for contraceptives, and for those who do have access, there is unmet need for counseling and better education on how to use contraceptives. There is also a completely different side of the reproductive rights coin – many women who want to have children cannot. Is it not a right to be able to have children when you want them as well?
For any woman who has been to the doctor or had a discussion with her partner about family planning, contraceptive use, and reproductive issues – she knows that one size does not fit all, and often multiple approaches and trials are needed before the right form of treatment can be found. This is the heart of the problem for women’s reproductive issues – they are singular and individualistic making intervention and education difficult.
In the past week I’ve had the privileged of shadowing field workers from the Willows Foundation and Planned Parenthood Association of Ghana. They are taking the individuality of reproductive rights to heart, and their work revolves around going to women’s houses, and sitting down one on one to discuss a woman’s concerns, questions, issues, and plans together. The field workers – men and women trained to discuss reproductive manners – are all individuals within the local community. I wanted to write about this experience and share a gimps into these non-profits and specific women that are genuinely making a difference.
Part 1: Emma
I’m supposed to meet Emma, a field worker for Willows, at 8:00am on Saturday morning near Hot Coffee – an area of Nima. Nima is a slum, but an old, well established slum. Most houses are durable, with electricity and some sort of water source. My cab driver has no idea where Hot Coffee is, and as we inch through the traffic for 20 minutes, I finally realize that he is looking for a shop called Hot Coffee. Frustrated, I get out of the cab and call Emma. Handing the phone to a random passerby, I ask them to explain where I am, and after a lot of hand-waving, I’m directed up the street to ‘Gutta’. ‘Gutta’ is literally a giant gutter that holds Nima’s sewage as it flows to the ocean (the map below shows a part of Nima, with the giant gutter cutting through horizontally).
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I get to Gutta, and call Emma again. We are trying to find each other but in the throng of people, cars, and chaos it is still difficult. She asks me what I look like and I laugh – I’m a giant white woman in a sea of black people, I shouldn’t be that hard to find. Finally a woman strides up to me. Emma is about 5’5, wearing an orange and yellow printed fabric dress at the knee. She is lovely, but also very serious, quickly taking my hand to greet me, turning, and immediately diving into the pathways between compounds that make up Nima’s housing. The paths are perilous with rocks, trash, and tiny gutters flowing with things you don’t want to step in. She is difficult to follow as she speeds to her first client, already an hour late because of me. I’m not too worried though – Ghanaian time is flexible, and lateness of up to two hours is acceptable.
Emma has no problem locating her first client of the day, which is honestly baffling to me as all of the compounds look exactly the same. The last time she was here was a couple months ago, which makes it all the more amazing. As we enter the compound, we are greeted, and curious eyes follow us as Emma inquires about her client. ‘You are welcome.’ A huge mango tree grows in the middle of the compound – one of the few pieces of vegetation that has not been chopped down as it has continuous economic value. Client 1 is a quiet woman, even smaller than Emma, wearing wrapped fabric around her waist and a ratty t shirt with a faded sports team logo. Her eyes are huge, and she could be beautiful if she didn’t look so tired. Emma pulls out the client’s card, and begins to go through her list of questions, mostly in Twi, a little in English. When was your last period, are you currently sexually active, are you currently using contraceptives… at this point Emma stops as the woman begins quietly explaining something. Emma looks at her sympathetically, and pats her on the shoulder. The woman’s husband exits the room, greets us, and leaves – he is obviously not disturbed that Emma is talking to his wife. The discussion is wrapped up, and Emma makes some small notes on the clients card. As we leave I ask Emma what was said. The woman has been married for almost four years, and she has not been able to get pregnant. Emma has been working with her to convince both her and her husband to go to the local clinic for infertility treatments, and the husband has finally agreed. They are soon to go for their first appointment, and the woman has concerns.
Client 2’s compound is a very different atmosphere. Clothes are hanging everywhere in the courtyard, freshly washed. Three teenagers are helping a bunch of younger children dress, all of them are laughing and playfully hitting each other. As we pull up some stools and sit with Client 2, she is dressing her 3 year old daughter who is demanding 10 pesowas for a toffee. Client 2 is a very kind looking woman, her body and hair are covered in traditional Muslim clothing. She is eager to discuss matters with Emma, while at the same time handling her daughter who is trying to throw shoes out of a bucket at anybody nearby. She has three children: a 9 year old boy, a 5 year old daughter, and a 3 year old daughter. She shares with Emma that she is currently pregnant – an unplanned and unwanted pregnancy. Emma goes over with her how to use the morning after pill, even though its too late for that now. She explains and gives her a booklet on IUDs, birth control implants, and the pill. The young girl manages to steal 20 pesowas out of Client 2’s pockets and runs off, returning a minute later with a toffee and 10 pesowas in change. The mother is not angry, but she gives us a pained look, sighs, and in English says, ‘one more’.
Client 3 lives in the same compound as Client 2. She has two children already, and does not want anymore. But her husband does not want to allow her to do family planning or use contraceptives. Her and her husband are currently using condoms, but the woman wants something more permanent. This is a situation I have wondered about, what will Emma say to this? Emma has no qualms whatsoever. She assures her that its a decision the woman can make on her own if she wants to, she emphasizes the idea that the woman doesn’t have to tell her husband about this, she repeats over and over ‘its your right’. I’m surprised, but also impressed. The client is obviously conflicted, and Emma does not push her, rather talks her through a number of contraceptive methods. The woman does not respond enthusiastically to any, until Emma gets to the shot – a method that is 1 cedi per shot (about .60 cents) and lasts about three months. The woman lights up, she seems to think a three month period is a nice amount of time, its not too permanent, and the pricing is reasonable. Emma asks her when she will go to the clinic for the shot, and the woman becomes uncertain again. Emma then quizzes her about using the morning after pill, and once Emma is satisfied that her client knows how to use it, we leave. I ask Emma if she thinks the woman will go get the shot, and she sighs and admits that it probably won’t happen.
We visit clients until about 11, when I have to leave for another appointment. We meet a woman who has two children, is 35, and her periods stopped after her second born. She wants more children but the doctors don’t know whats wrong. Another woman is concerned about a lump in her breast – Emma feels it and urges the woman to visit the clinic immediately. Another client is 25, has never had a period, but is having regular sex with a boyfriend. Emma encourages her to visit the clinic to assess why she has not menstruated, and also explains the perils of unprotected sex. The girl does not look convinced. One woman has six children – and does not want more. She proudly tells Emma how to use the morning after pill, something that Emma has been working with her to learn to use. We also visit a woman with two boys, pregnant with her third child. With the help of Emma’s visits, the woman and her husband have decided to get an IUD after the birth of the third child. They are hoping for a girl.
Emma walks me back to Gutta, and after I catch a tro-tro I see her dive back in between the houses to continue visiting clients. Emma is patient with her clients, but also straight and to the point. She does not look down on their decisions, rather gently encourages and informs them, continuously repeating information with each visit. She is kind. Emma is not paid for what she is doing – its a volunteer effort on her part. But she diligently visits clients most days. Willows Foundation and PPAG have about 30 field workers meeting with more than 3,000 clients in the Nima/Maamobi neighborhoods. They have registered over 16,000 woman, and over the coming years hope to visit them all. Their efforts are not going un-rewarded, but change is very slow – so far just over 600 women have started using some form of family planning as a result of the program. Many woman who are visited do not immediately alter their behavior. It often takes multiple visits on a field worker’s part, spread out over a year or more, to see some kind of change. Emma notes that the most difficult aspect of her work is misinformation. One woman may try a method that doesn’t work for her, and then she doesn’t want to try anything again, while at the same time telling her story to her friends and kin. This kind of social networking can be a challenge and a blessing. Emma is basically working to break down and reform these strings of information, so that when women do share their experiences with other women, they can be more informative and positive. Change is happening: when I asked Emma if she thinks the program is working, she simply says ‘yes’.