“Why should women have all the responsibility for family planning?” – Parmila’s Story

This is the second blog in a 4-part series sharing personal family planning stories from around the world – presented by CARE and Girls’ Globe in the lead up to the 2018 International Conference on Family Planning. Catch up on the whole series with stories from HawaOun Srey Leak, and Olive.

When it comes to family planning, women in India (and in the rest of the world) are expected to do the work. This reality is consistent across the various methods of contraception, but the disparity between the sexes is especially obvious when it comes to permanent contraception, or sterilization. For each man who opted for a vasectomy between 2016-2017 in India, 52 women got tubectomies.

The 1:52 ratio is striking, especially when you consider that vasectomies are cheaper, less invasive, carry a lower risk of infection, and have a quicker healing time than the female equivalent.

In recent decades, the procedure has been improved with the advent of the no-scalpel vasectomy (NSV), which boasts an even quicker healing time and lower risk of infection.

For couples who do not want to have any (or any more) children, the NSV can be a great option, and one frontline health worker in India has made it her personal mission to increase uptake in her community.

Photo by CARE

This is Parmila Devi with her husband, Bigan Sahni.

Parmila is an ASHA (Accredited Social Health Activist) in Bihar, one of the most populous states in India. She learned about NSVs as part of the ASHA family planning training, and she immediately decided it was the best option for her family.

“Why should women have all the responsibility for family planning?” she wondered.

“The first thing I did after becoming an ASHA worker was to convince my husband to undergo a vasectomy,” said Parmila. Bigan “thought she had lost her senses” at first, but eventually came around to the idea.

The procedure was a success, and Parmila began to tell her clients about her husband’s experience. She attempted to address concerns and correct myths and misconceptions prevalent in the community.

“Some men think [a vasectomy] would affect their sex drive or their ability to enjoy sex. Some also feel it would make them physically weak, which is not the case,” one state health official explained. Many women shared the same fears for their husbands.

ASHAs typically work most closely with women and children, but because Parmila wanted men in her community to understand the benefits of NSV, she talked to them as well.

“‘Ab ee mardo ken a chori!’ (She will not even leave the men alone!) the people in the households I visited in the early days would say.”

Bigan supports his wife’s efforts, and occasionally they make house calls together and he counsels the husband while Parmila talks to the wife. Gradually, people in her community have become more accepting of NSV as a viable method of permanent contraception.

Parmila received an award from the health minister of Bihar, Mangal Pandi, for motivating 43 men to get NSVs in 2017. Her goal for 2018 is to increase that number to 100, and so far, she’s over halfway there.

Given the volume of accurate information and quality family planning methods available now to individuals, we should be working to ensure this information and these services reach women and men.

There is no reason women should have to bear all of the burden for family planning and contraception in this day and age. Fortunately, there are activists like Parmila in this world to remind us of that, and to push us to be better.

Learn more about CARE’s work in Bihar here.

This case study was collected by Gaurav Masih, MPH candidate at Indian Institute of Public Health – Gandhinagar.

“All men should let their wives start family planning” – Hawa’s Story

This is the first blog in a 4-part series sharing personal family planning stories from around the world – presented by CARE and Girls’ Globe in the lead up to the 2018 International Conference on Family Planning. Catch up on the whole series with stories from Parmila, Oun Srey Leak, and Olive.

Under the hot sun of Maiduguri, Nigeria, 23-year-old Hawa Ngoma is fanning herself with the end of her black hijab (a full head-and-body cloak that most Nigerian Muslim women wear) while sitting under the shade of a tree outside of a health clinic.

Hawa is married and has a five-year-old daughter and a two-year-old son. Her husband, Ali, is an ambulance driver for a United Nations project. Hawa came to this particular clinic after Ali learned about family planning from a midwife who works with him and heard that CARE was offering it here for free. “When my husband heard and saw the benefits of the family planning from his work, he asked me to start family planning and get counseled by this particular midwife.”

CARE Nigeria is providing much needed facility and outreach-based models of sexual and reproductive health service delivery in the most hard-to-reach areas in Northeast Nigeria. Over 250,000 women and girls most severely affected by the crisis have been reached with services including pre- and post-natal care, family planning, HIV testing, health education and post- abortion care.

“When I came to the health center, the midwife explained all the different contraceptive methods to me and how to use them, the good parts and the bad.” Hawa shared. When I came to the clinic, she was really welcoming and warm and took all her time to explain everything to me and gave me the chance to ask as many questions as I wanted and did not feel annoyed at all. This made me want to come back and visit again when the time to change the implant had
come.”

Hawa wanted to find the right method that fit her body and lifestyle, and something Ali would like as well. “I wanted to go for the pill, but my husband told me it makes you grow fat and he loves the way I am already, so I tried the shots. I loved the shots, but I decided to go for the implant because it lasts three years and this will help me rest and not worry about it for that period of time.”

Although Ali now understands the benefits of family planning and supports Hawa using contraceptives, that was not always the case. “After our first daughter was born, he refused to let me start family planning.” At this time, Ali lived in a different town from Hawa for his work. “My husband did not want to hear about family planning and since he was not living with us, it
was easy not to get pregnant. After we started living together, I got pregnant right away and gave birth to a baby girl who died a few days later. Then, because I was not using contraceptives, I got pregnant 40 days after the death of my baby.”

Hawa’s second and third pregnancies were difficult. “For my last two pregnancies, I lost a lot of blood and lost consciousness. After the second one, I had a blood pressure issue,” Hawa explained. “After my second pregnancy, I was introduced to family planning but my husband was against it. I guess the difficulties and challenges we faced during my third pregnancy made him realize it was a mistake not to space births.”

Although acceptance of family planning is growing in her community, many men still do not approve of it. Hawa sees that as a problem. “I’d like to tell men that they should let their wives start family planning as it reduces the risk of suffering and allows them to give birth to healthy babies. It gives you the time to rest and to give a better upbringing to your children instead of having a baby sucking on your breast, one on your back and the other one bothering you for being hungry or because they have messed their pants!”

Hawa hopes to be able to go back to school, find a job, and be financially independent. She wants to grow as a woman and give her children a better education and to raise them to be good people who will help others.

Learn more about CARE’s work in Nigeria here.

In Her Hands: Normalizing Menstruation in Nepal

In Nepal, approximately 290,000 women and girls menstruate every day. However, 82% of those living in rural Nepal use unhygienic and potentially dangerous menstrual hygiene management methods. A study from UNICEF revealed that 1 out of 3 girls in South Asia knew nothing about menstruation prior to getting their first period.

Based on societal ignominy, menstruation’s direct barrier to girls’ health and education remains a hushed conversation. As a result, both household dialogue and policy making discussions often leave menstrual hygiene management (MHM) off the table.

Menstruation signals a girl’s entry into womanhood and reproduction. It is a crucial time for adolescent girls to learn about their bodies and their health. Silence and stigma surrounding menstruation impinge on girls’ lives, as the inability to manage menstrual hygiene affects education, physical health, psychological and emotional well-being, as well as overall quality of life.

Old taboos surrounding menstruation die hard in rural Nepal. One extreme example is the customary practice of ostracizing women and girls from their own homes during their periods, known as ‘Chhaupadi pratha’. Chhaupadi – which is based upon the belief that menstruating women are impure – prohibits menstruating women and girls from inhabiting any public space and socializing with others.

The effects of Chhaupadi are extremely dehumanizing and psychologically stressful, with young girls being told that they will bring bad luck on their families if they enter their own homes during menstruation. In addition to being emotionally degrading, Chhaupadi places women and girls at risk of rape, abduction, snakebites, animal attacks, and malnourishment. Forced to sleep in rickety huts without adequate insulation or ventilation, women and girls face illness exacerbated by the cold and unhygienic conditions or in extreme cases, even death due to asphyxiation from improperly ventilated heat sources.

Despite being outlawed by the Nepalese Supreme Court in 2017, Chhaupadi retains a foothold in the country’s western region and continues to put constraints on the potential, action and participation of women. Even in regions where Chhaupadi is not practiced, taboos surrounding menstruation still severely affect Nepalese women and girls. Many modern households in Kathmandu still prohibit menstruating women from entering kitchens or temples, eating with the family or sleeping on their own beds.

Managing menstruation in resource-poor settings is often challenging. Buying a sanitary napkin is a luxury most rural women can’t afford, and so many end up using cloths, rags and – in extreme cases – straw, sand or even ash as menstrual absorbents. Such challenges are further increased by societal taboos, ignorance and embarrassment around menstruation.

The plight of women in Nepal deeply motivated me to break the silence around menstruation by starting a dialogue, and so I founded a Project called ‘In Her Hands’. It aims to destigmatize menstruation and encourage conversation through…

  • Advocacy campaigns on menstrual hygiene management
  • Focus group discussions
  • Facilitating access to sanitary materials and physical infrastructures like female friendly toilets and safe water sources
  • Capacity building activities for adolescent girls

The goal of our initiative is to start a dialogue around menstrual hygiene and liberate girls and women from silent suffering. We are working towards ensuring that girls have a voice in their communities so that their menstrual hygiene needs are taken into account. We also want to make sure that they have full control over their bodies, and that they are part of a world in which every woman and girl can manage her menstruation in privacy, safety and dignity.

The pilot project was conducted in the village of Ramdaiya Bhawadi in Janakpur, Nepal. Since beginning in early 2017, our work has benefitted more than 500 women and we are looking forward to expanding to other areas of need in the near future. The initiative has sparked conversation about a topic that many people previously felt uncomfortable talking about. It has also helped facilitate policy change at the local level while catalyzing action and commitment towards securing the basic human rights of girls and women.

Despite increasing evidence for taking urgent action, menstruation remains a neglected public health, social and educational issue that requires prioritization, investment and concentrated effort at national and local level. I believe that girls and their individual stories should be at the forefront of development and if menstrual hygiene management is included as a part of the conversation surrounding policy changes, we will be able to spark change.

Project ‘In her hands’ has recently been awarded the ‘Student Project for Health Competition 2018’ by Foundation for Advancement of International Medical Education and  Research (FAIMER). It was also recognized as one of the Top 12 finalist projects in the Opportunity Desk Impact Challenge 2017 by the Opportunity Desk.

Menstrual Pain is a Public Health Matter

Menstrual health is a topic that is often neglected and ignored. In particular, issues pertaining to menstrual pain can be overlooked because of the silence that surrounds it. However, I recently read an article in Cosmopolitan magazine about period pain. It mentioned Professor John Guillebaud, of University College London, who has described the severity in pain as being “almost as bad as a heart attack”.

However, it remains true that many doctors dismiss menstrual pain as irrelevant when brought up by a patient. As a practicing doctor, I have come across patients in casualty complaining of period pain. Shamefully, I admit that I have trivialized these women and their pain or regarded them as ‘hysterical’ because my internalized sexism chooses not to believe them or expects them to deal with the pain (it’s all part of womanhood, isn’t it?). I believe many other doctors, both male and female, have harboured similar thoughts. As a result, women to wait longer for medical attention and sometimes receive inadequate pain management.

Menstrual pain interferes with the daily life of one in five women. The two main causes of menstrual pain have been found to be primary dysmenorrhoea or endometriosis. It is often difficult to differentiate the two because they can present with similar symptoms. Endometriosis can be difficult to diagnose – in some instances the process can take up to a decade. Doctors have struggled to find the specific medical causes for primary dysmenorrhoea. This may be related to the poor quality or low volume of sufficient scientific and medical research into menstrual pain.

I believe that the society and culture we’re in chooses to ignore menstrual pain or completely disregard it. At times males cannot relate because they cannot share the experience. As women, we are not taught not to discuss menstruation openly and to keep the great physical and emotional distress we may have to go through to ourselves.

In the workforce, menstrual pain is seen as a hindrance – yet another reason to deny women equality in the workplace. In schools, girls and young women are shamed for their pain and as a result, many choose to stay at home if the intensity increases.

There are changes that need to take place regarding menstrual pain:

  • Increased awareness around menstrual pain and its causes
  • Open discussions about menstrual health in the media, schools, offices and GP rooms
  • Consideration of period leave for girls and women
  • Working to removing the stigma around menstruation more widely
  • Increased scientific research into menstrual pain, including causes & management
  • Access to adequate and safe pain management for women
  • Recognition of menstrual pain as a public health matter

Menstruation is a normal biological process and we should not shame women for it. We must not neglect menstrual pain or matters surrounding it. We need to open dialogue and provide more medical information on menstrual pain to help the many women who suffer silently.