KNOWLEDGE SHARING FAMILY PLANNING

1. Context andBACKGROUND

In Rwanda and other African countries, one major factor contributing to the development challenge is the continued rapid growth of the population. The number of people in need of health, education, economic, and other services is large and increasing, which, in turn, means that the amount of resources, personnel, and infrastructure required to meet the Millennium Development Goals (MDGs) is also increasing. In light of this fact, development efforts in support of the MDGs should focus on the importance and benefits of slowing population growth.

With the highest population density in Africa (321 inhabitants per square kilometer), a very young population (67% of Rwandans are under the age of 20) and a fertility rate of 6.1, Rwanda urgently needs to develop Family Planning interventions that address the real obstacles preventing women from accessing and/or using services.

Regarding FP in particular, CARE believes that the low contraceptive rate of 10% is not only due to geographic accessibility problems but also to socio-cultural factors and unequal power relations between men and women. CARE seeks to better understand the social-cultural factors that hinder access of women to FP services with the ultimate objective to develop a community based reproductive health initiative, focusing on family planning. CARE received support from the Reproductive Health Unit through the Knowledge Sharing Fund. The learning initiative will be implemented among and with participants of CARE’s existing programme, such as Voluntary Savings and Loan groups, People Living with HIV&AIDS, adolescents and other marginalized groups.

2. General information on FP in Rwanda

Rwandan women have on average about 6 children each, and the unmet need for FP services is high (36 percent of married women of reproductive age want to space or limit births but are not currently using any method of family planning).

If access to family planning services was increased, this unmet need could be met, therefore slowing population growth and reducing the costs of meeting the MDGs.

A multi-country study titled “Achieving the Millennium Development Goals: The Contribution of Family Planning,” (USAID) looks at how one strategy—meeting the need for family planning—can reduce population growth and make achievement of MDGs more affordable in Rwanda, in addition to directly contributing to the goals of reducing child mortality and improving maternal health. According to that study, reducing the unmet need for FP services can help Rwanda significantly reduce the costs of meeting the five selected MDGs, including:

• Achieve universal primary education

• Reduce child mortality

• Improve maternal health

• Ensure environmental sustainability

• Combat HIV/AIDS, malaria, and other diseases

Therefore, Family Planning (FP) is among national priorities of the country. According to the draft of National Family Planning Policy and its five - year strategies (2006-2010), “the broad objective is to ensure healthy citizens who are able to work both for themselves and for their nation’s development.” Ministry of Health, (2006).

The same document reveals that specific objectives are related to giving birth to a number of children that iswithin the capacity of each household to support, in such a way that every family and the entire population as a whole will be more productive and then be able to contribute to the sustainable development of our country.

The major elements forming this draft policy are seven,stated as follows:

Focus on advocacy;

Mainstream Family Planning Programs in all health services and to increase access to full range of methods;

Partnerships in administration structures;

Community mobilization;

Assure quality & formative supervision in public and private sectors;

Sustainable (continuous) financing in family Planning;

Evidence –based decision making

Some researches and studies have been done in FP and Reproductive health (RH) in general in Rwanda. The main knowledge on FP is given by the Demographic and Health Survey (DHS) report, the most recent one being DHS 2005.

According to the DHS 2005 (INSR and ORC Macro, 2006), “at the end of her childbearing years a Rwandan woman has an average of 6.1 children”. The same findings show that women in urban areas (4.9) have lower fertility than those in rural areas (6.3).

Regarding FP, 95% of women and 98% of men aged of 15-49 years reported having knowledge of at least one method of contraception. However, only 13% of all women have correct knowledge about the fertile period, and 72% have incorrect knowledge or don’t know that there is a time during the menstrual cycle when a woman is likely more to conceive.

In addition, the use of contraceptive method by Rwandan women is very weak: 17% for any method and 10% for any modern method.

Women who were not using contraception and don’t plan to use it in the future gave their reasons; important ones are summarized below:

14.2% of women reported the fear for side effects;

9.9% wanted to have as many children as possible.

9.9% said it was forbidden by their religion;

6.7% are themselves opposed to contraception;

4.3% said it was forbidden by her husband/partner.

3.8 %reported the fear of health concerns;

2.3 % reported the lack of knowledge.

DHS 2005 findings show also that 59% of Rwandan women and 39% of men have never heard any message on FP in magazine, journals, radio or television, which means a big gap in communication. Radio is the most frequent source of FP message (41% for women and 60.7% of men).

The DHS (2005) findings have also shown a breach on providers’ side in their ability to approach the potential clients, namely non users. Indeed, in the 12 months preceding the survey, 90.5% of nonusers of FP had not discussed FP with a field worker or at health facility. Opportunities to provide information on FP are missed at health facility site: 18.6% of FP nonusers women have visited health centers but did not get any information on contraception.

There are still taboos regarding discussions on FP between spouses. 29.7% of Rwandan women have not discussed contraception with their husbands during 12 months preceding the survey. This is a serious issue and understanding why could help the increase of contraceptive prevalence.

The survey revealed the power of the man in decision-making regarding contraception. In fact, among 11% of all couples who have diverged opinion on contraception, in 10% of couples, women approve but their husbands don’t, and the reverse is true in only 1 percent of couples. 59% of couples have the same opinion and both partners approve contraception.

Despite all efforts by the government, UN agencies, civil society and NGOs, in Rwanda, unmet need for FP is high: 38% of women have expressed need for FP, among them 25% to space births and 13% to limit them but they remain unserved.

3. Literature review:

In Rwanda, apart from DHS reports which remain the most reliable national source of information, not many studies have been conducted on FP. Among the few documents done on FP, we can cite the following:

-“An in-country qualitative assessment of family planning in Rwanda”, conducted in 2002by The Ministry of Health, Advance Africa, the DELIVER Project and PRIME II and supported by USAID/Rwanda;

-“A study on the integration of FP in PMTCT services in the hospitals of Byumba and Kigoma”,conducted in 2004 by the Ministry of Health in collaboration with Intrahealth /PRIME II, with USAID support;

-“The Family Planning needs in formerProvinces of Butare and Byumba” conducted by GTZ and Health units of the two Provinces (2004),

-“The Impact study of the introduction of the Standard Days Method (SDM) in Rwanda” conducted by the Ministry of Health in collaboration with The Institute for Reproductive Health of Georgetown University and Awareness Project (2007);

The in-country qualitative assessment of family planning in Rwanda(The Ministry of Health, Advance Africa, the DELIVER Project and PRIME II, 2002)aimed to respond to three major issues:

Identification of barriers and opportunities for improving access of quality family planning services at service delivery points

Assessing the impact of the genocide on sexual and reproductive behavior andContraceptive use

Determine Community perspectives on religious and socio-cultural barriers which impact contraceptive use.

In trying to knowwhy Rwandan women don’t use FP services, the assessment found out various reasons, which are summarized below:

a)Lack of decision-making power of women in the household:men, women and adolescents considered men to be the primary decision makers related to sexual and reproductive health decisions for both men and women. This was identified as a major obstacle for women who were concerned about the consequences of making independent decisions regarding the use of family planning services.

b)Socio-cultural and religious influences:There was a consensus in the community that religion has a major influence on people’s capacityto use family planning services. The Catholics reinforce traditional Rwandan concepts of“childrenare gifts from God” and further entrenches culturally held beliefs against use of modern contraceptives. However, the Anglican Church emphasizes family welfare and has promoted family planning since the 1980s. The Moslems also encourage child spacing and are not against family planning services.

c)Informal relationship with multiple partners: Although polygamy is not extensive, the assessment found that informal relationships and multiple sex partners are becoming increasingly common as a result of the genocide.

d)Insufficient access to health services in general:due partly to the physical terrain and lack of transport for women to travel to health centers for “preventive” non-emergency services.

e)Insufficient information and counseling on family planning:Men and women consider that there is a lack of information on family planning. IEC messages were non-existent in the health centers visited either as a guide to health care providers or to the clients who came for other services. Radio programs rarely address family planning, whereas HIV/AIDS awareness campaigns are organized throughout the country.

f)Fear of side effects as a result of use of modern FP methods: In all six districts, there were repeated and consistent complaints among men, women, adolescents, and community leaders regarding potential side effects from the use of contraceptives.

g)Rumorsassociated with Family planning: Discussions in the districts indicated that there were strong rumors regarding family planning. Family planning use is associated with causing sterility, cancer, and miscarriage. Some even said that condoms are not safe because Europeans inject HIV into condoms and sell condoms for commercial purposes.

h)Perception of family planning as “limitation of births” only:Family planning has become synonymous with the limitation of births rather than an intervention to improve the health of both mothers and children. This most probably results from the former ONAPO (Office of National Population) policy prior to 1994, which operated purely from demographic targets.

i)Difficulty in using natural family planning methods:While natural family planning methods are culturally accepted, the majority of respondents felt that without strong discipline, self control by men, it is difficult to be effective. The services for helping women with natural family planning services are not currently available. Alcohol was also mentioned as another problem. For women who are illiterate counting from calendars was mentioned as one of the obstacles for effective use.

j)Specific problems associated with widows, separated and divorced womenwho face significant obstacles in accessing family planning services mainly because of lack of confidentiality at the health center.

k)Lack of access, awareness, and support of adolescent reproductive health services:

l)Early marriages were said to be a problem in some districts as the use of health services among this group is low, which places them and their children at greater risk of disability and death.

m)Impact of the genocide: The genocide has had a significant impact on both fertility and contraceptive use. The significant number of households headed by widows, single women, orphans and wives of prisoners have changed household organization and gender relations. As a result, sexual relations among men and women outside of marriage have increased for various reasons. Men have a greater tendency to have multiple partners and co spouses women “compete” in such relationships by having more children.

n)Factors associated with poverty which impact contraceptive use: communities link high fertility and low contraceptive use with poverty. Low fertility was associated with “better standards of living”, “less kwashiorkor” better health and “harmony”.

The study on the integration of FP in PMTCT services in the hospitals of Byumba and Kigoma (Ministry of Health, Intrahealth /PRIME II, 2004), had the goal of analyzing the situation and contribute to the development of an approach for evaluation and if possible, reinforcing and improving the integration of FP services in PMTCT activities.

The assessment evaluated reasons of low attendance by women of FP. The findings revealed the importance of rumors and exaggerated fear around side effects of modern FP methods. Among those persistent rumors, it was said that modern FP methods lead to women sterility, non stop menstruations, congenital deformations, headaches, too much weight; many people thought also that condom could migrate into the uterus.

According to the assessment conducted in former Butare and ByumbaProvinces by GTZ (2004), essential needs in reinforcing FP services were among others “means to sensitize the population from the grassroots”. This assessment report revealed also that ignorance of the population and the influences of religion were key causes in women’s unwillingness to FP.

The results of the Impact study of the introduction of the Standard Days Method (the Ministry of Health in collaboration with The Institute for Reproductive Health of Georgetown University and Awareness Project, 2007)revealed that contraceptive prevalence increases with community mobilization done by health centers.But, providers mentioned traditional mentality that children are gift from God, rumors on exaggerated side effects, and resistance to change as key obstacles to the increase in contraceptive prevalence rate.

Many of those studies, researches and assessments quoted above confirm the socio cultural barriers preventing women from accessingFP services. In brief, socio cultural barriers stated in cited documents can be summarized as follows:

Lack of decision-making power of women in the household

religious influenceson people’s capacity to use family planning services

informal sex relationships and multiple sex partners

strong rumors regarding family planning

Specific problems associated with widows, separated and divorced women

Early marriages

Impact of the genocide:

rumors on exaggerated side effects, and

resistance to change;

In addition, this literature shows two main issues:

On the one hand, there is recognition that socio-cultural barriers and men/women power relations are part of the access problem. At the same time, there is a lack of an in depth and profound knowledge of these two aspects, including religion. The objective of this research will therefore be to explore these two aspects in more depth.

On the other hand, the review also leads to the conclusion that FP programs must engage and involve men and Church leaders more actively and strategically. This research will explore how to engage men and church leaders in FP programs.

4. Information on the existing use of theater in Family Planning / reproductive health programs in Rwanda and elsewhere

CARE has got extensive experience in other countries in Social Analysis and Action(SAA) and would like to test that during this research.

Social analysis builds on and utilizes familiar participatory approaches, but with variations that encourage the development facilitator to work with communities to ask themselves the difficult, unspoken questions about their social realities, to unlock patterns of communication that have the potential to not only achieve better project results, but to see real changes in community members’ sense of pride, strength and dignity.

In other words, exploring SAA requires to build on everything you know about engaging communities in participatory dialogue, but to set aside some of the boundaries and assumptions that have limited that dialogue in the past.

Three concepts central to social analysis and action are:

Seeing people as lead actors in their own development processes and not just active participants in exercises intended to address those needs;

Breaking out of sectoral boxes that circumscribe our work and limit its impact; and

Embracing CARE’s role as a catalyst and facilitator of change, rather than just a provider of development services.

Social analysis and action opens doors to new discussions with communities around issues of health from a social lens. Social analysis often involves the use of interactive theater. This is good in terms of program but does not apply easily with small and rapid research context. However, if CARE Rwanda develops a community-based Family Planning intervention, it plans to use social analysis throughout the intervention. Therefore, the use of theater in this original research has two objectives: 1. To test the feasibility of using theater as a tool to pass on messages on FP and to collect sensitive information from participants 2. To start the process of social analysis within CARE Rwanda’s FP intervention. It is in that context that CARE has been looking for successful experiences using theater in the region and particularly in Rwanda and in Reproductive Health programs. The following relevant experiences were identified: