Growing up in suburban Montreal, I was blissfully unaware of the struggles of the world. As a 10-year-old sitting in class completely embarrassed about the topic of sexual education — learning about the normal changes our bodies will encounter, what is menstruation and how to prevent pregnancy and sexually transmitted infections — I was spoiled on so many levels.
Firstly, that I was a girl receiving an education; secondly that I was receiving this vital information; and thirdly that, if needed, access to pregnancy prevention was readily available. I learned how special this was during my first mission in the Central African Republic (CAR) after receiving many questions about how our body works, in particular about pregnancy, by the community and the community health workers (CHW).
These concepts had been repeated during years of primary and secondary education back home, but grown adults had never even heard of the word “puberty” in Zemio. Once, I asked the national staff if they were ever taught about puberty and sexual health — I was met with blank stares and a mission to accomplish. After the first two-hour session with the CHWs on puberty and creating anatomical body diagrams, the response was more than I expected. The CHWs went off into schools, churches and community meetings explaining the basics of our bodies to all age groups and were asked repeatedly to return. From there, other topics related to reproductive health were better understood and received, most notably family planning.
The maternal mortality rates in Sub-Saharan Africa are the worst in the world, the Democratic Republic of Congo (DRC) amongst the worse, and family planning can greatly improve health outcomes for women and infants. In summary, we describe family planning as spacing out and planning pregnancies to give mothers and infants time to recover and grow healthily. Once I arrived in DRC, I was very curious to understand how family planning and sexual reproductive health was perceived, understood and accepted. In contexts where women’s rights are not fully respected, it is difficult to negotiate the use of family planning.
A member of MSF's health promotion team gives a sensitization to a group of mothers in one of the communities we serve
Walikale is no exception. In our specific context, when a husband decides he would like to have another child, as childrearing is seen as a sign of wealth and strength for the man, the women comply. Many times I was told that the use of condoms as a barrier method is only used by sex trade workers, and women who request family planning are seen as promiscuous and unfaithful. We were even met with accusations that our male health care workers inserting implants or giving injections as family planning methods did so that they could have secret affairs with the women.
When the health promotion team and I first began introducing the subject to communities and their leaders, we were met with resistance, false beliefs and long impromptu discussions about marriage and the legal implications of family planning. The most frequent statement that would arise was, “You are telling us that we should not have so many children! You are trying to make us stop.”
Another popular belief was that a woman was legally required to have a man’s consent before practicing family planning. The challenge of integrating family planning into communities seemed much more daunting and complex here than in CAR. Despite this, I still saw an opportunity to educate and break down the barriers, ultimately for the health of families. The resistance and misunderstandings seemed to be greater the further from Walikale. Hence, we started with our CHW network within Walikale, which is the “hub” town of Walikale territory, and we were met with some resistance, but within a few weeks the use of contraceptives in our health center increased pretty drastically. In a two-week period, we went from implanting three women to 26.
Next was a village 12 kilometres away. Again, a week after our teachings with the CHWs, I met a couple who was about two months post-partum and came requesting an implant after they heard their CHW talk about the concept within the community. Although the numbers didn’t stay that high in Walikale, and it wasn’t as high an impact in the next town, we were still reaching the population and we could see the fruits of our labour.
In the furthest health centre district we support was where I knew we would have the biggest challenge. One afternoon while I was talking with the village chief and his entourage in the hut in front of his house, we got into a 45-minute discussion about family planning, often being met with the statements and myths mentioned above. At some points, men in the hut raised their voices in passion while explaining their points of views. I understood that the people present were not only an accurate representation of the community, but also the leaders and change makers, and it was important that they be heard and that each question was addressed. By the end of the 45 minutes, we agreed that during our next visit we would plan a mass sensitization session targeting men and that the chief would help us spread the word. He did not disappoint!
Brigitte posing with some female MSF staff members on International Women's Day
We did not know what to expect, but when we arrived in the afternoon about two weeks later, the chief was at the gate within an hour and asking if we had a megaphone so that he can go through the neighborhoods and encourage all men to come to our sensitization. The health promotion supervisor and I were so excited. We could hear him for the next two hours yelling in the streets advertising our session, even early the next morning we could hear his voice being carried across the low-lying clouds. We were not sure how many people would show up, maybe 30, 40 maximum, but we knew that if we could reach even two men, we would consider this session successful. With each new couple adhering to family planning they would talk to their families and friends and we would slowly see an increase in curiosity, acceptance and use.
Well, by 14h30 we had over 80 men in the hall and three women, but not just any women — these were the female chiefs of the village. Our team started by questioning the crowd and seeing what they already knew regarding the subject and corrected some misconceptions. I think the most sobering answers as to why family planning was important was given that day: “Because if an armed group enters the village and you need to flee, it is much harder grabbing many children. You will most likely lose some and be delayed.”
Once the education began, I was so proud of the three members standing up there and captivating their audience. The hall grew quiet and we even had a few men taking notes about the advantages and different methods available. When the session ended, we were asked to repeat the session again during our next visit, to include more women and that we should bring more condoms. I knew that the objective of the session was obtained when there were two men who individually approached our team members to speak more discreetly about family planning options.
Overall, the numbers of patients adhering to family planning did go up slightly; however, the team and I understand that it will require frequent education sessions and time to break the barriers towards family planning. In August, access to family planning will be more readily available with the opening of the Tumaini sexual reproductive health centre. Although I will not be there for its opening, I know that the team and I have already started to plant the seed for its success.