Families and communities have a large impact on the decisions that women make about their health. Pressure to conform to expectations or traditions can lead women to make poor choices, like rejecting family planning and contraception. But some communities and families are working together to help women to make smart decisions and gain access to vital resources.
"It's seen as insubordination"
According to the United Nations Childrens’ Fund (UNICEF), many Sierra Leoneans, especially in rural areas, don’t decide on the size of their family ahead of time. The agency says up to one third of all maternal deaths and injuries could be prevented if women used contraceptives to space births or prevent pregnacy. Greater spacing between births allows a woman to recover from delivery and restore nutrients needed for a healthy baby.
A 2008 demographic and health survey by the group Statistics Sierra Leone indicated that only five to eight percent of women use contraceptives, although they are legal and available at most pharmacies.
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A report released last year by Amnesty International, Out of Reach: The Cost of Maternal Health in Sierra Leone found several reasons for the failure to plan ahead.
It found that for families struggling to feed themselves, contraception is not a priority. Also, women in Sierra Leone do not have much say in the size of the family or the spacing between pregnancies.
A single woman is subordinate to her brother and father – a married woman to her husband, who makes family decisions, according to the Amnesty study. “A woman’s social standing depends on her role as a mother, and it increases as she has more children.”
The report also found that many women rejected family planning, including birth spacing, out of fear of being abandoned or rejected by their relatives.
If a woman delays sex after childbirth, she insults her husband, says Brima Abdulai Sheriff, the director of Amnesty International in Sierra Leone.
“It’s seen as insubordination,” he says. “The family of the wife [can be] fined to pay [the husband] rice, palm oil, goat or sheep. Woman will be asked to publicly apologize or explain if she’s feeling sick. Even educated women here cannot refuse their husbands.”
The problems with family planning and poor maternal health are also due a lack of public awareness.
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“The community has to be involved and that is paramount, and once you have the community, the family, the health facility and the health worker all working together, then you will have a perfect health system,” says Freetown private medical practitioner Dr. Donald Bash-Taki.
Things are beginning to improve.
Dr. Ibrahim Thorlie, a consultant obstetrician and gynecologist with the Princess Maternity Hospital in Freetown’s East End neighborhood, says recent government reforms provide free health care for pregnant and lactating women. The government is also training more midwives and working to make more clinics available in rural areas that can provide pre-natal care.
Mobilizing families and communities
Everyone, including men, must get involved in ensuring good maternal health, says Thorlie.
“Every individual must play his or her own role. They should know when to go to the hospital when their wives, daughters or relatives are pregnant. If every family knows what to do and [where to go], that should be a way of reducing infant and maternal mortality.”
To encourage family planning, experts recommend social mobilization and awareness-raising campaigns, including dramas and broadcasts about the importance of pre-natal care and assisted delivery.
Amnesty International Director Brima Abdulai Sheriff says his organization uses theatre and other methods to appeal to men to help guarantee a safe pregnancy. It’s part of their role as leaders in the family, says Sheriff. “They’re responsible for the pregnancy,” he adds, “and [a man’s] children carry his surname.”
Traditional leaders are also getting involved.
Sheriff says some now instruct young women to seek pre-natal care at the nearest clinic.
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Among these leaders are “Mammy Queens,” he says,“wives to the chiefs or wives of local traditional leaders or [they are] elders of the community who wield a lot of power and have control over women. They may also have relationships with [traditional birth attendants] or local government authorities. So when they take decisions …they are respected within the community.”
He says poor women are [more likely to follow] customary practices and resolutions taken in the communities. They are afraid to go against the law. Abdulai says women in some communities contribute to a common fund to provide for transportation or other needs of pregnant women.
The effort to get families and communities involved in maternal care is beginning to pay off, says Thorlie. That joint effort, combined with the removal of health care fees for pregnant and lactating women, is leading to a decrease in maternal and child mortality rates.