Feedback from community dialogues on women's and child ...

Listening to the voices of women in

KwaZulu-Natal

Mkhonzeni Gumede, DramAidE

Richard Delate, JHHESA

The Partners

Background

• Proposal developed at request of KZN Office of the Premier, Department of Health, Department of Social Development and UNFPA with additional funding through USAID/PEPFAR.

• Develop a women’s and child health advocacy, communication and social mobilisation (ACSM) strategy and operational plan.

• Aligned to support the attainment of the MDGs

Lets start by asking communities.. Align to Sukuma Sakhe Programme

• The Provincial Government of KwaZulu-Natal (PG-KZN) has launched Operation Sukuma Sakhe (Let us stand and build), which promotes a partnership between the KZN Provincial Government and communities to rebuild the fabric of society and the nation, with a particular emphasis on women and girls.

• Participatory communication is on-going dialogue with and between the audience and continues over time through a process of mutual adjustment and convergence (Piotrow, et al., 1997).

• It utilises social mobilisation activities to mobilise the communities to work together to find solutions to address the challenges to women and child health within their communities.

• It allows greater insight to be obtained into the lives of “individuals” through drawing upon the audiences’ knowledge of their peer networks, family relationships, partner relationships, community relationships, and societal norms.

Location of the community dialogues District

Municipality

Local

Municipality

Community Date Female Male Total

Ethekwini Durban Metro Umbumbulu 15-Nov-11 68 17 85

Ethekwini Durban Metro KwaXimba 16-Nov-11 74 44 118

Sisonke Ingwe Bulwer 17-Nov-11 101 23 124

Ilembe Mandeni Hlomendlini 18-Nov-11 104 34 138

Umkhanya-

kude

Hlabisa Makhowe 24-Nov-11 96 40 126

Zulululand Phongolo Ncotshana 19-Nov-11 N/A N/A 110

Uthungulu Mlalazi Mbongolwan

e

21-Nov-11 89 53 142

Ugu Umdoni Amahlongwa 22-Nov-11 98 40 138

Umzinyathi Nquthu Kwanyezi 23-Nov-11 129 105 234

Umgungundlov

u

Umsunduzi Nhlazatshe 2011/11/23 92 45 137

Uthukela Imbabazane Moyeni 24-Nov-11 N/A N/A 77

Amajuba Newcastle Mdadeni 25-Nov-11 N/A N/A 500

Total 851 401 1929

Structure of community Dialogues

• Structured to encourage maximum community participation and involvement.

• Plenary Session – used Forum Theatre – where a scenario is sketched that the audience discusses and attempts to solve.

• Small Group discussion – segregated by age and gender using different techniques to look at their community situation. – Body Mapping – participants draw diagrams to share their

knowledge and insight of the health issues confronting people in their community.

– Image Theatre –the audience creates frozen pictures based on an idea, theme, or key moment in a story.

– Community Mapping – participants create maps of the resources and infrastructure available to the community.

– Story telling – participants share personal stories with group members, bringing to the fore issues they wish to highlight.

Issues addressed in the community dialogues

• The key issues addressed during the community dialogues were identified by the Steering committee established by the partners to oversee the implementation of the campaign. These included: – Low rates of contraceptive use amongst women and

girls linked to high rates of unplanned pregnancies. – High rates of HIV infection – Late bookings for ANC by pregnant women – Low levels of exclusive breast-feeding by pregnant

women – Sexual and Gender Based Violence

Ethical considerations and Limitations

Ethical considerations: • All dialogues were recorded using video recordings, observational

notes and tape recordings. • Participation was voluntary. Participants were informed at the

beginning that the discussions would be recorded for reporting purposes. All participants were given the opportunity to opt out or to observe the discussions.

Limitations: • Recording of the small group discussions was a challenge as there

were insufficient note takers available. This may have resulted in a loss in the nuances in the recording of some of the discussions, a dependency on flip chart notes and the reporting back by the group rapporteur that may result in reporting bias.

• Insufficient time to cover all the topics identified.

Presentation on the Key Findings from the Community

Dialogues

Low rates of contraceptive usage

Health care worker attitudes – Negative attitudes and the lack of confidentiality by health care

workers towards clients seeking family planning hampers the ability of clients to make informed choices that result in unwanted pregnancies and that may lead to self induced attempts at abortion. Nurses refuse to put us on injections and stuff so that we can

prevent pregnancy (Participant, Amajuba) The health care workers treat us badly when we got to the

clinics. So we don’t go back. They ask us why we want to use contraception, and sometimes they refuse to give us contraceptives because we are too young and they threaten to tell our parents (Report back, KwaXimba).


• Knowledge and experiences of using contraceptives – Within relationships contraceptives have a symbolic meaning that is

tied to issues relating to fidelity, love and trust.

They see us as unfaithful if we use contraceptives; they think we are having secret lovers (Participant, Amahlongwa)

– The effects of contraceptives on women’s bodies inhibit their uptake especially if they do not meet the satisfaction of their male partners. Side effects include: making women too wet during sex, weight gain, changes body shape or a loss in appetite.

– Men confirmed that women using contraceptives were unattractive describing them as having loose bodies and popping veins.

– There is also a belief that they will not be able to fall pregnant at all or for the same period as they were using contraceptives.


Contraceptive usage and violence

• In some instances the use of contraceptives by women may result in physical violence and an ending of the relationship by their sexual partners.

If they see their girlfriends visiting family planning clinic, they beat them up and dump them and then call them names (Participant, Umbumbulo)

Low rates of contraceptive usages

Gaps in Knowledge of Family Planning • Low levels of knowledge of emergency contraceptives and

PEP in communities.

What is that for? Where you get it? Because it’s the first time I hear about it. (Participant, Amajuba District)

• Men report having very low levels of knowledge of contraceptives and family planning and often excluded from the decision making process around contraceptive usage.

Men must be taught about the importance of using a condom and family planning (Report Back, Pongola)

Men do not have a problem with taking part in family planning as long as

you explain to them properly why it is important that they do that. Some women want to stop giving birth for their own selfish reasons and not because of health reasons (Enquthu, Community dialogue)

Termination of Pregnancy

Stigma and rejection of teen pregnancies • Across all community dialogues reports of self-induced

terminations of pregnancies. • Lack of support from male partners, fear of reactions from

parents (including being kicked out of the house) and the community at large are key drivers of self induced pregnancies.

Females abort unborn babies, not because they want to, but

because they have pressure from their boyfriends or simple want to hide the fact that they ever became pregnant, this is for various reasons (Bulwer)

We are afraid to tell our parents when we are pregnant because we may be chased away from home (Participant Mbongolwane)

Termination of Pregnancy

• Lack of confidentiality by health care workers vs confidentiality by illegal operators is main reason why young women revert to illegal abortions.

There is a high rate of backstreet abortion here. Our boyfriends do not want us to use contraceptives, if we do they beat us up, what’s disturbing is that they even refuse to use condoms and when we get pregnant we go for backstreet abortion because we cannot afford to be seen by the nurses (Participant, Umbumbulu).

• Across the districts, the same cocktails being used by young women for self-induced termination of pregnancies were mentioned

Disinfectants, gobho (traditional muti), stameta (some muti sold in traditional pharmacies); chrystal potassium, permanganate, aspirin added to coca-cola which is boiled (Participant, Amajuba).

High Rates of HIV and HCT

Multiple sexual partners

• Identified as a key issue across all the community dialogues fuelling new HIV infections.

• Relationships are secretive in nature and often there are suspicions that people have multiple partners.

They do not want to be seen in public with their partners as they may have other partners (participant, Amajuba)

The phone is a problem because she does not answer it in front of me she goes outside. But when it is her sister she does not go out and she does not want me to answer her (Participant, Makhowe).


Sugar Daddies: • Across all dialogues reports of older men, “Sugar Daddies”,

engaging in transactional sex with younger women for material goods.

The love of money, hence the dating of older men also leads to teenage pregnancy (Report Back, Hlomendlini)

• There are reports of predatory sex/rape where gifts and favours are given by older men with the expectation of sex. When sex is not provided this results in the man forcing the young women to have sex with her.

Next to my house, a girl 17 years of age fell in love with an old man who was moneyed. One day he took her forcefully to his friends place and said you have been spending my money and you don’t want to sleep with me and he slept with her by force.

High rates of HIV and HCT

Condom Usage • Condom usage is symbolic of casual sexual relationships and the lack of

trust or love. Where female partners insist on the use of condoms this is often rejected by their male partners who accuse them of cheating or that they do not love them.

We don’t use condoms because men refuse them (Participant, Amajuba) We love them that is why we do not use

• In transactional sexual relationships the power dynamics between the male partner as the provider and the younger female partner’s dependency on their financial support often results in the male partner dictating the terms and conditions (including condom use) of sex within the relationship.


Alcohol and Drug Abuse • Multiple sexual partners are strongly linked to alcohol and drug

abuse consumption, resulting in high levels of casual sex and inconsistent condom usage.

• Shebeens and taverns target young people operating in close proximity to schools

...taverns are all over, alcohol is easily accessible. Also, taverns are very close to schools. Thus a number of young people (13-19) are addicted to drugs. Alcohol use among pregnant teenagers was also pointed out as one of the major problems (Report Back, KwaXimba).

It is a challenge though for selling alcoholic drinks to the community

because it (the tavern) is next to schools, young people may get easy access and influence from it.(Community Mapping, Pongola)


• Alcohol is used as a form of transactional sex between older males and younger females, “Kati and Ubisi game” (Mayor, Amajuba).

In other instances older men buy younger women alcohol with the expectation of having sex with them in return. In some instances men and women get so drunk that they cannot remember who they have slept with or use condoms inconsistently.

• In one area there were high levels of appreciation expressed by the community members at the closure of taverns and shebeens in the community.

Some parents are glad that these taverns have been closed because it

reduced the availability of alcohol whilst others that drink felt that it was unfair that they now have to travel long distances to get alcohol (Community Mapping, Nhlazatshe).


• Having sex while under the influence of alcohol results in participants not using condoms and thereby putting themselves and their partner at risk of HIV infection.

A lot of our peers drink a lot and when we are drunk we don’t use condoms (Report back, KwaXimba)

Access to condoms

• Access to condoms within communities remains a key barrier to people being able to use condoms, with condoms primarily being available through health facilities, and not always readily available in communities at times when people need them as the facilities are closed

Male Participant: We don’t have condoms, the clinics run out of condoms

Facilitator: So the clinic is the only place where you can get condoms, is there no other place?

Group: Yes the clinic is the only place.

• The low levels of availability of female condoms within communities were noted as a concern. In one community female condoms were regarded as empowering women to take a stand and be in control of their own lives and never let men control them by deciding on condom use (Nhlazantshe, Community Dialogue).


Low Levels of HCT amongst men • There are low rates of HCT amongst men and men use the status of

women as a proxy of their own status, however, testing was reported to be more prevalent amongst younger men.

• Where men discover that their partner may be living with HIV they abandon their partners believing that they have brought HIV into the household.

It’s not as easy as you may think….you don’t know men around here…they refuse to go for HIV testing, and it’s not easy to be the one who bring the bad news at home, anything is possible…your marriage might end and you’ll be left alone with a fatherless child. (Female participant, 19-25)

• The fear of being abandoned by their partners and being left alone to raise the child also results in women not disclosing their HIV status to their partner.


• Men are reluctant to undergo HCT owing to the lack of male friendly services, health care worker attitudes, concerns relating to privacy and confidentiality.

Male participants voiced out that this clinic is not user friendly and they also prefer male nurses because it is difficult to disclose to female nurses. This clinic use is a challenge because nurses know them in the community and there is no confidentiality (Report Back, Amajuba).

• Men accessing health care services are seen as weak or fear knowing what their health problem may be. Men report that they do not have adequate knowledge of men’s health services; prefer to be attended to by male health care providers. The lack of efficient and confidential health care services is a key barrier to the uptake of services amongst men.

• Men use the traditional health care system as they are more familiar with the traditional system and its readily and easily available to them in areas in which they live.


• Participants recommended that couples counseling and testing be promoted so that men can also test for HIV together with their partners at the onset of the pregnancy.

We need to start testing for HIV together with boys who impregnated us (Participant, Pongola)

Care and Support for Pregnant Women

Men, multiple partners and pregnancy • Men are reluctant to accept responsibility when their partners fall

pregnant and accuse them of having more than one sexual partner.

We might not be fathers since females have got more than one partner

(male participant, Amajuba)

• Having multiple partners implies that men may not be able to provide support to their pregnant partners owing to competing demands on their time from other partners.

We are not faithful to our partners and we have a lot of girlfriends on the

side so you find that it is not easy for us to give our partners all the love and support they need during the pregnancy (Male Participant, Makhowe).

Care and support for Pregnant Women

• There are low levels of awareness amongst women of the need to visit antenatal clinic services early on in their pregnancies.

Traditional Health Care providers • Traditional health care providers are the first to be consulted to receive a

traditional tonic, Izihlambezo, that is known to facilitate the pregnancy. “We never thought that there was anything wrong with not going early to

the clinic when one is pregnant especially if one is visiting the old mama in the community for isihlambezo (this is a traditional medicine used on the pregnant women) and many women use it”. (Inhlazatshe Community Dialogue)

Traditional medicine is used the most by those that are pregnant called

(izihlambezo)For some reason this group does not prefer clinics as they do with local women using traditional medicine (Bulwer Community Dialogue).


Accessing Health Care Services • The physical distances, staffing shortages in clinics, opening and closing

times of clinics, long queues and lengthy waiting times are barriers to women access health care services timeously.

If you want to go to the clinic you may need to hire a taxi and taxi’s are expensive, ambulances take forever and other people live across the river where transport is a big problem which is why we go to our traditional healers (Participant, Umbumbulu)

More nurses must be employed in our local clinics so that they can be able to help us without delays…The local clinic must be opened everyday and every time so that we can get help every time (Participant, Pongola)

The nurses are forever in meetings in the mornings, work few minutes its lunch break before you know it the clinic is closed (Amajuba Clinic)


Mobile Clinics

• Infrequent visits by the mobile clinics result in long waiting queues, which may result in some patients not being attended to and/or having to wait till the following month or to travel to other areas in order to access health care services at their own expense.

They rely on the mobile that comes once a month and cannot cater for all the community members. It was reported that people come in numbers and the mobile clinic runs out of medicine much to the irritation people who waited all day long in the queues to be told that they cannot be treated. Others hate the fact that they have to wait all day long in a sun or sometimes on a windy day (Report Back, Inhlatzatshe).


Attitude of Health Care Workers • Both younger women and older women reported that the attitude

of health care workers to women who are pregnant is a key barrier not only to early antenatal bookings but also to overall health checkups.

Because sometimes they get pregnant when they are still very young

causing nurses to shout at them when they go to the clinic for a checkup (Participant, Enquthu (Kwanyezi)

We experience negative attitudes from health care workers when we attend clinics, especially if we are older and pregnant. They ask us why we are still having kids when we are old, why don’t we prevent, but we can’t because our husbands don’t listen to us and they don’t want to use condoms.

Care and Support for Pregnant Women

Accessing Emergency Medical Services

• Within communities’ access to emergency services for women who are delivering are limited with several participants noting the slow response times of ambulances in responding to the

needs of communities.

Sometimes the ambulance will be phoned when one is on the verge

of labour and it will take a very long time to come and this results in complications. (Report Back, Nhlazatshe)

Accessing Antenatal Care Services

Communities value clinics that work:

• In one community there was a high level of appreciation for the clinical services as these services were available seven days a week.

We said that our community services available to us as the clinic

works, the nurses work and the clinic is now open 7 days a week (Report Back, KwaXimba)

Our clinic even though its small the nurses work a lot (Report Back, KwaXimba)

Post Natal Care and Support

Low knowledge levels of the benefits of exclusive breast feeding • Mixed levels of knowledge around the benefits of exclusive

breastfeeding within communities for the prevention of HIV. In some instances women know that breastfeeding has protective benefits for babies born to mothers living with HIV. For other women there is no knowledge of the benefits which is reinforced through health care workers.

Some pregnant women put their babies’ lives at risk by insisting on breastfeeding their babies even when they have been told by nurses not to (Participant, Nquthu).

Breast milk is the foundation of life and it protects you from HIV and

AIDS...(Participant, Mbongolwana)


Stigma and discrimination and infant feeding • The manner in which a mother feeds her baby is often used as a

signifier of her HIV status. The high levels of stigma within communities towards women living with HIV acts as a barrier towards safe infant feeding practices.

Most HIV positive mothers in the area cannot cope with PMTCT because they do not disclose to their partners. Most of them know about exclusive breastfeeding but they fail to put it into practice because stigma associated with being HIV positive (Report back, Mbongolwane).

Most participants reported that they mixed feed because they are afraid of

the stigma that is associated with exclusive feeding whereby the in-laws diagnose the person by scrutinizing the baby feeding process (Report Back, Amajuba).


• Men use women’s status as a proxy of their owns status and as a signifier of HIV status – the feeding practices of women is often scrutinized by men to determine the status of their partners - if a women is suspected of being HIV positive he will leave his female partners.

We worry that we will lose our husbands and also be suspected of sleeping around.That’s why we hide the real reasons for not breastfeeding. (Participant, KwaXimba)

Postnatal Care and Support

Working Mothers and Exclusive Feeding • Exclusive breastfeeding is a big challenge for working mothers. The

baby is left behind in the care of grandmothers or others who may feed the child with other foods.

A mother might go to the clinic and find out she is positive, she will do her best to give her baby only breast milk but the grandmother or mother in laws will not allow that, when they send the mother to the shops or to go get water, they will feed the child different foods, that’s when the baby gets infected.

• Where mothers choose to express milk for feeding while they are away from their children this is often insufficient to meet the needs of the baby.

Its difficult to leave enough breast milk in a bottle when you working long hours (Participant, Amahlongwa)


Impact of breast feeding on women’s bodies

• Women have real concerns regarding the impact of exclusive breastfeeding on their body images and therefore may resist to continue breastfeeding fearing that it may make their breast sag or them appear less attractive.

Some young women refuse to breastfeed their babies because they believe that if they do then they will stop having a cleavage or beautiful full breasts (Participant, Nquthu).

Others are afraid that their breasts will sag and they will lose their cleavage (Participant, Hluhluwe)

Violence Against Women

• There are strong linkages between gender based violence and the factors that place women at risk of HIV infection and unwanted pregnancies. Multiple partners and the linkage of condoms to infidelity make it difficult for women to introduce condoms within existing relationships.

• Men are still the primary decision makers as to when and how sex will take place, the use of condoms and contraceptives. Attempts to introduce contraceptive usage within the relationship may result in domestic violence in particular where men have not been consulted.

Violence against women

• Men regard respect and sex as a right within the relationship. When sex is withheld the male partner accuses the women of cheating which may result in violence.

• There are some reports that men are socialized to use violence as a corrective measure and a symbol of ‘love’ – to discipline a partner is to show love and will result in greater love and respect.

It feels so good to hit someone you love, she just loves you more

(Male participant, 19 – 25, Umbumbulu)

Sexual violence against women

• Alcohol was regarded as a key driver of gender based violence. This was linked to the opening and closing times of the tavern and that women who consume alcohol may be vulnerable to rape or sexual violence when leaving the tavern or shebeen.

Number of taverns close late and are always full and high alcohol

intake that result in violence (Amajuba, Community Mapping).

• Women also experience sexual violence within the home where they are raped when their homes as a result of house break-ins.

Women exposed to HIV, STIs and unwanted pregnancy as a result of

rape while on their sleep-house-breaking (Report back, Umdoni)

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