E2A Newsletter, April 2016
Speaking out: DRC’s Lualaba Province on access to family planning
In this photo slide show, see the women and men—clients, community-based distributors, service providers, and health officials—in Democratic of the Congo’s Lualaba Province who enthusiastically told us about what community-based family planning services mean to them.
Communities in DRC express enormous demand for family planning: Asking E2A—“Where was your project before? What were you waiting for!?”
In Democratic Republic of the Congo’s (DRC) Lualaba Province, women of all ages, young men with small babies, older men with their wives, adolescent girls and boys—they arrived in droves at a central market and they gathered in large groups under the trees at a community park to socialize, shop and sell, and, many, for the first time, to pick up a contraceptive of their choice.
E2A staff selected the market and the community park as ideal sites for the project’s outreach events. Outreach events are part of an innovative approach applied by E2A’s USAID Mission-supported community-based family planning project in DRC’s Lualaba, Kasai Central, and Lomami provinces. The project provides rural populations with access to high-quality family planning services where it makes sense: in their homes, at nearby places where they already frequent and gather, and at local health centers.
The project currently serves hard-to-reach areas in 15 health zones and 51 health areas in the 3 provinces—a small segment of an expansive country. There are 515 health zones across DRC, a country that spans close to 1 million square miles.
E2A: What were you waiting for!?
“People have been asking me ‘where are you coming from?’ ‘What were you waiting for?!,” said Huguette Mumba, 25, a community-based distributor who was at an outreach event held at a central market in Fungurume, DRC, to provide information on family planning services.
At the outreach events, which are held twice a month in each health area, community-based distributors like Huguette provide women and men with information about family planning, including all the methods available: contraceptive implants, injectables (DMPA), male and female condoms, progestin-only and oral contraceptive pills, and Cyclebeads. If they want a method, Huguette refers women and men to a temporary clinic set up for the day. Several nurses from the nearest health centers coordinate with community-based distributors at the outreach events to provide support and offer counseling and contraceptives for free in the temporary clinics.
At a cost of approximately US$60 per outreach, these events are a cost-effective innovation for offering family planning services to women and men who do not have the time or means to make it to the nearest health center. In a span of 3 hours at the Fungurume central market, 355 people became new family planning acceptors. Nurses administered 11 implants and 2 injectables, and distributed 107 Cyclebeads, 28 female condoms, 114 male condoms, 34 progestin-only pill packs, and 59 oral contraceptive pill packs.
Where was your project before?
“Where was your project before?,” asked Maurine Tshinngo Mwinza, a 24 year-old woman and unmarried mother of two at the outreach event organized in a community park in Mutshatsha, DRC. Mutshatsha is a rural area disconnected from Kolwezi, the nearest city, by 180 kilometers of largely red dirt road, filled with enormous potholes, large rocks, and newly formed ravines.
Maurine was at the park to refill her supply of oral contraceptive pills. “I wouldn’t be an unmarried mother with two children right now if I had had contraceptives,” said Maurine, pictured below.
“Women in Mutshatsha are very happy to see the methods in this community so household incomes can improve,” said Mwenze Banza, 33 and mother of 7. She was at the outreach event to receive a contraceptive method for the first time in her life.
“I want to stop having children. Seven is enough,” said Mwenze.
With poor roads and infrastructure in many regions, the delivery of family planning services to women like Maurine and Mwenze has been extremely limited. This has resulted in women continuing to give birth despite limited means to support large families and a desire to stop having children.
According to the last Demographic and Health Survey, conducted in 2014, the average number of children Congolese women have in their lifetimes is sky-high: more than 6 in urban areas and more than 7 in rural areas. Only 8 percent of married women of reproductive age are using a modern contraceptive method. In the provinces where E2A works, the statistics are even more extreme: in 2014, between 4 and 5 percent of women in each of the 3 provinces were using a modern method.
But things are slowly changing in Lualaba Province.
Change on the horizon
“I decided with my husband to take an implant today,” said Veronique Kabadi, who received the fifth implant of the day in the clinic set up at the back of the Fungurume central market. Veronique, 44, who has six children, said she wants to stop growing her family. “Because of the number of children we have and our household income, we cannot support the children.”
Veronique, like many there at the market that day, heard about the availability of contraceptives, including implants, from a community-based distributor who works in her village. Community-based distributors, like all the cadres of service providers engaged by the project, are trained to provide information on family planning using an approach that encourages the involvement of men, including couples counseling when possible.
“Because I have been elected in my community and most people know what I do, they trust me,” said Paulin Mushid Ngwej, a community-based distributor who is 47 and a father of 7.
Like most other community-based distributors, Paulin was a health volunteer prior to being trained by E2A to sensitize his community about family planning and to offer counseling and non-clinical methods. E2A has trained 408 community-based distributors in the 3 provinces on provision of family planning services and child health services including oral rehydration salts and zinc for dehydration.
It is because of community-based distributors like Huguette and Paulin that Mathilda Mwepu, 28, and her husband Simeon Kabila Lwabanza, 32, can live out their wish of spacing their next pregnancy.
“I had two children, but one passed away,” said Mathilda. “We want to space our next pregnancy by four years.”
Simeon and Mathilda, who pulled up her sleeve to proudly show off her implant, now refer to themselves as “positive deviants.” They help to spread the word about the value of contraceptive choice with their communities, to their friends and family members. They are the organic result of communities who are enthusiastic about finally having access to family planning services.
“If many people get information from us then we are doing our jobs,” said Mathilda.
Community-based distributors are one group of several that raise awareness about family planning services in their communities through E2A-supported demand-generation activities and refer women and men to outreach events and the health center for clinical services. Other demand-generation agents mobilized through the project are: 250 health development committee (CODESA) members; 250 community leaders; 175 community champions; and 300 youth leaders.
Almost 200,000 people have been reached in the 3 provinces with information about family planning and child health through these groups.
Manika: Women take the lead
In HGR health area of Manika health zone, uniquely among E2A sites in DRC, female community-based distributors outnumber men and a woman, Konike Upite, serves as president of the zonal health development committee—referred to as a CODESA.
“We make sure women can be involved in activities for women’s empowerment,” said Koniki. “We discuss different topics related to health and make strategies related to problems in our communities.”
“We go to where men are when they return from work and discuss family planning with them and stay in touch with other men in our communities,” she continued.
Currently there are 8 community-based distributors, 7 women and 1 man, serving HGR health area.
“Women were asking us questions: ‘Where were you? Why weren’t you coming before?” said Koniki, speaking of her dual role as a community-based distributor of family planning services. “If many women accept family planning in the future, we can put in strategies for spacing pregnancies.”
The E2A Project covers 3 health areas out of the total 13 health areas in Manika. Despite its limited coverage and timeline in Manika (10 months to date), contraceptive uptake has increased significantly across the zone: from 15 percent to 28 percent.
A main objective of E2A’s interventions in DRC is to engage both men and women in the delivery and uptake of family planning services. Doing so requires that communities and institutions tackle pervasive gender norms that have historically hindered the ability of women to make decisions about their sexual and reproductive health.
By having more women, like Koniki, sit on and lead CODESAs, women have a platform to speak out publicly, voice the priorities of women in their communities, and share some of difficulties women face. By raising these issues, men can better understand and support women to make productive decisions about planning their families and bettering their lives. Women’s representation on CODESAs has increased since project inception: from 17 percent to 30 percent of CODESA members.
E2A has also intentionally recruited female community-based distributors to the project. In many communities, it is not acceptable for a man to visit a woman in her household alone, so women are in a better position to speak to other women about family planning, especially when men are absent. Of the 408 community-based distributors recruited and trained by the project, 55 percent are women.
E2A has used a participatory training approach to build gender awareness and capacity across different groups involved in demand generation and service delivery: provincial and zonal health officials including those who serve as supervisors and make quarterly visits to oversee service delivery in each health area, traditional leaders, nurses who deliver family planning services, and community-based distributors. These groups then work with communities to encourage reflection on the gender issues that have shaped their lives and communities and support positive norm and behavior change.
“At the start of the program, the men were not convinced of family planning, but now there are men that come to me and try to have access to information and contraceptives,” said Kashala Mokuta, who, as one of the older community-based distributors in the HGR group, married and had her family long before community-based family planning services were available. She now has 14 children and many grandchildren.
“The main challenge was a woman accepting a method without informing her husband, but now we have local radio conducted by health zone officials and have made progress,” she said.
Kashala refers to radio segments, where, three times each week, officials and community leaders speak out about important topics to the communities, such as communication between men and women about family planning. The project has leveraged these existing community radio programs to raise awareness.
“Men have learned that the woman is not just an instrument of a man,” said Jimmy Ngoie, Chief of the Health Zone.
He said that since the inception of the project, male community-based distributors have started to change their behaviors and have become, in effect, models for shifting gender roles. “Male community-based distributors have decided to change their own behavior,” he said. “There are men who cook on the weekends and cultivate together with their wives.”