In 2016, I traveled to the Democratic Republic of the Congo (DRC) on assignment for Pathfinder International. My job was to write a 7,000 word project report for the client, the David & Lucile Packard Foundation, focused around lessons learned and human-interest stories. To write the report, I interviewed the Congolese people that the sexual & reproductive health care project supported to tell their stories.
You can read an excerpt from the report below.
1. LESSONS LEARNED: COMMUNITY MOBILIZATION
In partnership with Pathfinder, Congolese organizations Solidarité des Femmes pour le Développement Intégral (SOFEDI), SOS Femme, Enfant en Catastrophe (SOSFEC), Si Jeunesse Savait (SJS), and Programme National de la Santé de l’Adolescent (PNSA) engage with communities to address negative gender norms and stigma around sexual and reproductive health (SRH), promote knowledge of SRH and available services, and develop allies and leaders to support sexual and reproductive rights.
1.1 Create a Climate of Support Among Community Leaders
When Viviane Sebahire began working in South Kivu, DRC with SOFEDI, the barriers to achieve comprehensive sexual and reproductive health and rights felt overwhelming. According to the DRC’s 2013-2014 Demographic Health Survey, 34.5 percent of women experience sexual violence in South Kivu. It seemed impossible to even know where to start.
SOFEDI, in partnership with the Pathfinding Safe Abortion Initiative, conducted a baseline study in Bukavu and Uvira in March 2015 to assess access barriers and attitudes surrounding sexual and reproductive health and rights (SRHR), including abortion. They found that unsafe abortion was extremely common and that the largest barrier to post abortion care was the lack of affordable services. But this was not a surprise. It was a different finding in the baseline study that made SOFEDI stop and reflect.
Through their qualitative interviews, SOFEDI found that when community members discovered that a woman had had an abortion, people immediately went to local religious and political leaders with the news. Leaders would then publicly shame the woman or even punish her, often with fines. This not only ostracizes the woman, it also pushes unsafe abortion further into the shadows. SOFEDI had originally planned SRHR awareness raising sessions for community members, but with this new information, they realized that they also had to reach community leaders. Leaders’ responses to abortion would determine how the entire community viewed SRHR.
Viviane’s strong ties to religious groups in South Kivu opened the door for SOFEDI to meet with religious leaders. Viviane began showing the study’s statistics to religious leaders. When the leaders understood the urgency of the issues, they referred her to other religious leaders. Once Viviane developed a network of religious, political, and traditional leaders, SOFEDI began organizing awareness raising sessions over eight months. In addition to sessions with 1,216 youth and adolescents, SOFEDI held sessions with 507 traditional, religious, and political leaders—195 of whom were women. The sessions included discussions of laws related to SRHR, including the Maputo Protocol and Security Council Resolution 1820, and included conversations on the effects of harmful social attitudes towards abortion and SRHR.
Viviane’s and SOFEDI’s hard work came to fruition when in January 2016, the Bureau des Oeuvres Médicales de l’Archidiocèces Catholique de Bukavu (the Medical Charity Office of the Bukavu Catholic Archdiocese, BDOM) contacted SOFEDI to co-author an advocacy document to integrate contraceptives into their budget. Beginning in July 2016, the Bukavu Catholic Archdiocese will provide contraceptives to health facilities—a huge success for change in traditional religious attitudes. Additionally, a traditional leader in Uvira told SOFEDI, “From now on, I will engage in the relaying of key SRHR messages to other traditional leaders, so safe abortion will become culturally accepted and eventually legalized throughout the DRC.”
As community leaders shape a progressive discourse around SRHR (including abortion), SOFEDI sees positive effects throughout South Kivu: citizens are reporting fewer abortion cases to community leaders and leaders are distributing fewer fines to women who receive abortions. This means that stigma is beginning to fade—a vital first step to reducing unsafe abortion.
1.2 Make Unlikely Allies
When SOFEDI issued their baseline survey to assess community attitudes and knowledge of SRHR issues in Uvira and Bukavu, they found that 91 percent of respondents knew at least one person who had had an unsafe abortion. To save women’s lives, SOFEDI couldn’t wait for the Maputo Protocol’s implementation.
SOFEDI decided to go to the source of unsafe abortions: the providers themselves. Through outreach with unlicensed medical practitioners and traditional healers, SOFEDI discussed the harmful effects of unsafe abortion. But SOFEDI didn’t just want to talk—they began to mobilize the unlicensed practitioners and traditional healers to become advocates for legalized abortion services.
SOFEDI is an expert in creating alliances among unlikely and disparate groups. Their work with unlicensed providers and traditional healers who perform unsafe abortions is no exception. SOFEDI shows that to rally a community around SRHR, you must include—not shun—those who may appear antithetical to your goals but have the potential to join your fight.
1.3 Know Your Cultural Context
Sometimes it comes down to choosing the right words. SOFEDI found that the term avortement sécurisé (safe abortion) made people skeptical of their work. Congolese people were not comfortable discussing or mobilizing around avortement sécurisé. According to Viviane Sebahire, the term evokes an image of sexual promiscuity and a lack of morals. With that knowledge, SOFEDI reflected on what language would be culturally appropriate for the South Kivu context.
After talking with community members and conducting experimental conversations, they found that it was most effective to speak about preventing the negative consequences of unsafe abortion and to discuss strengthened SRHR as a solution to sexual and gender-based violence (SGBV). When SOFEDI framed the conversation in this way, it appealed to a wider audience.
SOFEDI learned how to harness their knowledge of Congo’s cultural context to make their work more inclusive, so that maybe one day, it will not be taboo to speak about avortement sécurisé.
1.4 Generate Genuine Demand
In Uvira, South Kivu, people often attack or avoid groups that openly discuss SRH and promote sexual and reproductive rights. Over the years, Annie Nturubika Indi of SOSFEC found that the most effective way to engage people is to not force ideas, but rather to gradually grow people’s interest.
Annie realized that SOSFEC could do this in two ways: make SRHR topics relevant to people’s everyday lives and serve as a resource and support system. Instead of addressing the health implications of unsafe abortions, HIV & AIDS, and SGBV, SOSFEC discusses the socio-economic consequences of these health issues. For example, when SOSFEC discusses HIV & AIDS, they point out the high number of orphaned and vulnerable children. This creates more opportunities for people to engage with the discourse.
SOSFEC frequently relies on the radio to reach a wide audience, especially those who don’t attend workshops or community discussions. Recently, SOSFEC created a radio segment about a fictional woman who unexpectedly became pregnant and wanted to end the pregnancy. She then visited a traditional healer for an abortion. Afterwards, she experienced heavy bleeding. The woman rushed to SOSFEC and they referred her to the Kasenga General Reference Hospital for post-abortion care.
SOSFEC presents itself as a stigma-free resource that people, especially adolescents and youth, can seek out for support—including for information on misoprostol. SOSFEC is careful not to seem imposing. Annie notes that demand is most often created when people informally recommend and share information about SOSFEC via word-of-mouth. That is why they develop communautes championnes— small groups of individuals who conduct outreach to others about SRHR issues, including post-abortion care, contraceptive methods, SGBV, and reproductive rights. SOSFEC pays special attention to engaging youth and community leaders. SOSFEC knows that when these groups have SRHR knowledge and support sexual and reproductive rights, it is possible to achieve large-scale changes in attitudes and cultural norms.
Since SOSFEC made SRHR a relevant conversation for all and proved that they are a safe, welcoming resource, they’ve observed that community members take greater responsibility for their sexual and reproductive health. More individuals seek out information and services, participate in awareness raising sessions on SRHR, and engage in advocacy efforts for the Maputo Protocol’s implementation.
1.5 Providers Aren’t Police
Programme National de la Santé de l’Adolescent (PNSA) (PNSR) increase citizens’ access to youth-friendly SRH services. But PNSA isn't only working with adolescents and youth to increase their demand for SRH services. PNSA has found that youth-friendly services are just as important as peer educators. Mimie Kabanga Kayembe notes that during youth-friendly services training for providers, it is important and effective to remind them that “providers are not the police.” It is not their job to judge.
Pathfinder’s youth-friendly services training, conducted in collaboration with PNSA, shows providers how their attitudes directly impact youth’s health-seeking behavior. PNSA developed a simple exercise to help enable providers to offer youth-friendly services. During a training, PNSA asked providers to reflect on themselves at age 16. Didier Lukieme explains that placing them back in their old shoes creates a moment of realization. Providers contemplate how they wish health providers would have treated them. They think about what kinds of information and services they wish that they could have accessed as sixteen-year-olds.
Didier and Mimie note that while the providers know they cannot go back in time to support their 16- year-old selves, they can do something today for a 16-year-old with the same questions and apprehensions.