Ethiopia: Women and contraception

"Contraceptives are a blessing for our country!" Sy Nuy Talib is absolutely convinced of her clearly spoken words. You can tell by the intense look on her face. The twenty-four-year-old has been working as a health extension worker for two years. "I visit eight to ten families every day. The total area I cover includes about 500 households. I go from house to house and offer people free advice on health matters. Family planning is a particularly important aspect in this context. I'm often the first person the people ever talk to on this subject," she says, describing her remit.
The Health Extension Program is one of Ethiopian health policy's few success stories. It was initiated in 2003 with the support of several governmental and nongovernmental organizations and significantly expanded in 2009. More than 38,000 graduates of secondary schools, almost all of them women, have so far become health advisors after completing a one-year training course. Now, like Sy Nuy, they are working mainly in the rural areas of Ethiopia where over 80 percent of the population live – and virtually no one has access to basic healthcare.

Sy Nuy Talib, 24, health adviser

"If it wasn't for our mobile health advisors, hardly anyone here would know anything about family planning," confirms Tefetawit Gebre Aregawi. She's a health officer in one of the four health centers in Adama, a city of 220,000 inhabitants 90 kilometers southeast of Addis Ababa. Every day she examines, advises and treats people from her day clinic's very large rural catchment area for free and supplies them with medications. "All the people in the country areas, without exception, are very poor. They struggle with existential worries every day: How can I get something to eat? How can I get work? In such a situation the problem of contraception is often seen as being secondary."
Like Sy Nuy, Tefetawit is 24 years old, just as clearly structured in her statements and just as committed. Going into more detail, she says: "People don't talk about sexuality anyway in the rural areas. Neither among friends, nor within the family. Our culture doesn't allow it."
In fact, the people are caught in a stranglehold of poverty, lack of education and age-old tradition – and each aspect influences the others. Tefetawit and Sy Nuy often meet women who were kidnapped by their later husbands between the ages of ten and fifteen. The men raped the girls until they became pregnant. Then they forced their victims to sign the marriage documents. Some managed to escape, but were sent back by their own families: they were considered worthless after losing their virginity.
As late as ten years ago, more than two thirds of all Ethiopian women were falling victim to this practice, which is still common today. They spend their lives in captivity and slavery, without hope of liberation even though these crimes have been prohibited by law since 2005. But outside Ethiopia's capital Addis Ababa, the police and courts hardly ever prosecute the crimes.

Tefetawit Gebre Aregawi, 24, health officer

"When the women come to me," Tefetawit continues, "I always have to take into account that they're afraid to talk to me. I try to reach them on a human level, not the official one. Only when they open up a little can we talk about family planning."
It is important to tackle this issue not only because parents can't feed their children, let alone send to school – there is also another reason: according to statistically substantiated UN estimates, 75 percent of Ethiopian women were still being genitally mutilated five years ago – mostly for religious reasons. Self-appointed circumcisers forcibly remove the girls' external genitalia at some time between infancy and puberty – with knives or razor blades, under catastrophic hygienic conditions. They then sew up the wound – permanently – using the most primitive of means.
This torturous, dangerous and traumatizing procedure leads to a plethora of physical and psychological problems. Intercourse causes severe pain. Many births involve complications and a deadly risk to both mother and child. And even today, every woman in rural areas has an average of more than five children.

Tefetawit Gebre Aregawi, 24, health officer

"The men often have no idea what pressures their women are under," says Sy Nuy diplomatically. "That's why they either refuse to face up to the subject or else reject family planning outright. There is also a persistent rumor that contraceptives lead to permanent infertility." A strong argument in a child-loving society. And an even stronger one when children are also seen as living proof of men's and women's fertility, i.e. as a status symbol.
Nevertheless, Sy Nuy's commitment is beginning to yield results: "After two years of continuous counseling, at least the women are slowly changing their attitudes. They trust me and believe they don't need to be afraid of contraceptives," she says, evidently pleased. "Because the consequences hit them harder, they usually make their own decisions anyway as to whether and when they use contraceptives, and what kind."
Tefetawit from the Adama Health Center, however, also talks about setbacks: "I have a woman patient," she says indignantly, "whose husband is a doctor himself, i.e. an educated person who is fully aware of all the facts. After taking detailed advice, she decided on a three-year implant. But she came back two days later, saying her husband was very religious and strictly rejected family planning. He even refused to talk about it. He was absolutely furious and even got aggressive. In the end," she says, shaking her head in disbelief, "I had to remove the implant."
Many women end up having unwanted pregnancies in this way. Abortion is their last resort. Teenagers in particular often have no other choice. Sex before marriage is forbidden, and they are denied access to contraceptives. Cultural and religious barriers make it impossible for them to talk to their parents on the subject. Yet all too often an abortion leads to even greater tragedy. "I had a friend at high school," Tefetawit recalls sadly. "She became pregnant at the age of 14. She wanted an abortion at all costs, but that was illegal at the time. So she went to one of the many quack doctors – and died from the effects of the operation. After that experience, I knew I must inform people about contraception."
The fate of Tefetawit's friend was not an isolated case. It has also happened to thousands of other women. Others have suffered serious effects as a result of botched abortions. At that time, this was the cause of death in over 40 percent of all cases involving pregnant women with access to a clinic. Because the deaths of women in regions without medical healthcare services do not appear in the statistics, the true number is probably much higher. As recently as 2002, the then conservative government enacted a new, extremely strict anti-abortion law. Physicians who conducted them risked five years imprisonment. Even the country's Marie Stopes clinics were all closed for several months. Marie Stopes is a British NGO that runs centers in over 40 countries offering family planning, safe abortions and follow-up care, medically professional births, maternal and child healthcare, the diagnosis and treatment of sexually transmitted diseases and HIV/AIDS prevention. Until they were closed down, women used to use them as a secret refuge when in distress.
The consequences of the new law were so disastrous that in 2005 the government was forced to legalize abortion in certain circumstances, despite vociferous protests from churches and other opponents of abortion. Today, every morning dozens of women again throng the courtyard of the Marie Stopes clinic – painted a friendly blue and white – in the Arada district of Addis Ababa.

Sy Nuy Talib, 24, health adviser

"We carry out 1,300 abortions every month," says Melkanu Rideper. The twenty-five-year-old nurse can hardly believe the figures himself. "I know from another Marie Stopes clinic that they have 1,500 a month. We have five hospitals in Addis altogether. In the two years when I worked in the countryside, there were also 500 to 600 abortions a month, even though the population density was much lower there."
Most of the patients at the Amada Health Center remind Tefetawit of her dead friend. "Many of them are under 15. They never received any sex education; nobody told them about contraceptives. And even if they know contraceptives exist, they usually have no access to them because the areas they live in are too remote." The situation is similar at the Marie Stopes clinic in Arada. "The girls are often afraid to talk to us," says Melkanu, describing a typical clinic consultation. "They invent all kinds of excuses until they finally get to the point. Most of them cry. They are in a deep mental and moral conflict. Their parents think they're at school, but in reality they're having an abortion. Some of them come every two to three months, but still refuse to use contraceptives because of religious taboos or for fear of being discovered."
Even Sy Nuy doesn't use contraceptives. Not yet, the unmarried Muslim emphasizes. That will change immediately once she is married. Religious rules have great power – even over those who provide sex education. Add social norms, ignorance and a lack of access, like in Ethiopia, and the result is an almost unassailable fortress. Yet Sy Nuy proves every day that it can be conquered: "When I started my job, my initial motivation was only to make money. The people were very suspicious towards me. I encountered a lot of rejection. It was exhausting and frustrating. But over time, I have achieved some very tangible successes. Now I see how I really help many women, how I change their lives. As a result I now really love my job. It's extremely important for our country."

Melkanu Rideper, 25, nurse

(Report, Photos and Podcast by matias boem, 2012)