Overcoming Barriers: Teens Accessing Reproductive Health Care in Zambia
Being a teenager can be scary and confusing, especially when it comes to your sexual and reproductive health. Teenagers in Zambia feel like they can’t approach their families or health clinics for information and services, especially when it comes to pregnancy and HIV prevention. Inonge Wina-Chinyama, an advocate with Marie Stopes International (MSI) Zambia, talks to us about how MSI is integrating HIV, contraception/ pregnancy prevention, and other general services in order to reach teenagers seeking sexual and reproductive health services in Zambia.
It isn’t easy for teenagers in Zambia to access SRHR services due to stigma, fear, and bias from families, providers, and communities. While Zambia’s government does employ comprehensive sex education in schools, there is an existing gap between education and service delivery. The size and location of communities means that there are limited discrete, safe spaces where girls can go and receive services without running into people they know. Many girls also experience bias by providers, who sometimes tell girls that they shouldn’t be having sex before marriage rather than equipping them with the information and services they need.
MSI has developed ways to meet the sexual and reproductive health and rights needs of girls in Zambia. When girls visit reproductive health providers, they are met with “teen connectors,” or other young people that have honest conversations about sexual and reproductive health care that girls are seeking before they meet the provider for services. The Divine Divas program is a brightly decorated youth center for young girls who want to talk to others about contraception, condoms, HIV, menstruation, anatomy, and more. MSI is also working to link contraception with a girl’s futures, dreams, and aspirations.
Jennie Wetter: Welcome to rePROs Fight Back a podcast on all things repro. I'm your host Jenny Wetter. In each episode, I'll be taking you to the front lines of the escalating fight over our sexual and reproductive health and rights at home and abroad. Each episode, I will be speaking with leaders who are fighting to protect our reproductive health and rights to ensure that no one's reproductive health depends on where they live. It's time for repros to fight back.
Jennie Wetter: Welcome to rePROs Fight Back. I'm your host, Jennie Wetter and today's episode should be a fun one. Um, being in Washington DC I get to take advantage of working with a lot of amazing organizations that bring in advocates from around the world to talk about sexual reproductive health and rights. So today I get to take advantage of Marie Stopes International, bringing in a wonderful advocate from Zambia. So today I'm going to talk to Inonge Wina-Chinyama with Marie stopes international Zambia about Zambian teenagers and sexual health. Hi Inonge
Jennie Wetter: Thank you for being here.
Inonge: Thank you for having me.
Jennie Wetter: Are you enjoying your time in DC?
Inonge: I am. I just came through this morning like early in the morning.
Jennie Wetter: Oh my goodness. Have you at least been in the states a little bit to like at least get on the time? Are you still,
Inonge: I think I'm still a little bit confused as being sort of different time zones. London. Then I went to Aspen, I went to Denver and I'm here.
Jennie Wetter: Good. Okay. So what is life like for teenage, for teenage girls in Zambia?
Inonge: Um, being a teenager in Zambia can be exciting. It's fun. You think you're in control of the world. You're in control of your own life sometimes when you're not, you know, when you're a teenager, I really outgoing. You have lots of friends who share secrets with. You talk about boys, you talk about your relationships, you talk about sex, but you don't really have, um, someone order whom you can talk to. You can trust. You always feel like, oh, I can't talk to that person. What if they go and tell mommy or Daddy? What if they think differently of me that I'm talking about sex, you know, so being young, the, they keep to themselves and talk about these issues without a lot of facts. Being young, you feel you can't go to a health facility to get any sort of support, uh, concerning your sexual health, um, decisions because you're too scared to do that. Teenage girls are very scared of pregnancy. Most of them more scared of it than HIV because when you get pregnant very soon everybody will know that you're pregnant cause the pregnancy will start showing. They're not scared so much of HIV because they think, oh, you know, I can get treatment. So for Marie Stopes it was a case for integration. Say how do you integrate, um, HIV and contraception or prevention of pregnancy. So being young can really be confusing, especially if you don't have someone to reach out to, to get facts about your sexual health.
Jennie Wetter: Is it easy for them to go out and access, um, services like contraceptive services?
Inonge: It's not really easy because sometimes just the culture itself does not allow you as a young person to go out there and start seeking for such services because you are not expected to be having sex. You know, how can you go out there and start looking for contraception? You are not supposed to be having sex. Sex is for us, who are older order, who are married. It's not for you. So you can't go out and start talking about it. Yeah. Too scared. And sometimes you, you can't because when you go to your facility, maybe the provider the is very biased. The provider, there might be mommy's friend who say, "Oh, I know your mommy. What are you doing here?" Um, so there's really lots of barriers. Even if go sometimes with when to come out and say, look, I really want to have sex. I'm not sick. I just want to have sex seriously, but where do I go to and feel that the service is discreet and it is private and now not be judged. So it's not the easiest to actually go out there and access services.
Jennie Wetter: So is the bias around being unmarried or being young, or is it both?
Inonge: It's actually both, but I think the hardest is being young and unmarried and without the chat, right? So sometimes it's easy when you've had a child before, everyone's like, oh, she already know sex. She's had a child before it’s okay for her to go out and look for contraception. But when you're not married and you do not have a kid, it's not expected of you to actually go out there and look for contraception. Um, I'll give an example on one of the times when I was out in rural Zambia doing my fieldwork, we had this young girl who came to me and said, oh, can I talk to you for a bit? And I go, "yeah, sure." And she's like, "Oh, I had sex once and I got pregnant, but I also got HIV. I had a little baby with her. And she was like, I'm, this is my baby who was maybe aren't six, seven months old. And he's also HIV positive." That was really sad. And the question was, is there hope for me? And I looked at her and I felt really sad because we had failed. There were lots of moments in her journey where we could have helped her. The time she was thinking of having sex, there was no one to talk to her about safe sex. The time she had unprotected sex, there was no one to talk to her to say you can actually go and get help in case you've contracted HIV. The time she discovered that she was pregnant, there was one to talk to, how to say you can actually protect your unborn baby from getting HIV. So those are the barriers of a young person. And she couldn't come out and ask anyone cause she was too scared. She had already made this big mistake where everybody was saying, you're a naughty kid who has been having sex. Look at you now you're pregnant. So where could she go to get help? All she needed was someone to facilitate that journey and all I did was to take her to the clinic while we were to say, here, let me take you to the nurse who help you. I wish someone had done that earlier. If someone had spoken to her before she had that first encounter of sex, the whole story would have been very, very different. Her whole journey would have been very very different. But now what you said to this girl comes to you and says, I'm HIV positive, my baby is HIV positive. What next? You know, is there hope for me? And you're talking about dreams and aspirations. How can I achieve my dreams and aspirations when I'm positive? So that girl represents a lot of girls, not just in Zambia, in Africa, globally. The girls who are like that, who we have missed in their journey. We've not been there to help them make decisions, the right decisions at those moments in their journey.
Jennie Wetter: So that makes me think, in Zambia, how is sex ed viewed? Is there a comprehensive sex ed that's taught in schools or out of school programs or is there not really sex education at all?
Inonge: Um, there is sex education and the, the, the government of Zambia is doing very well with comprehensive sexuality education. What goes on, learning about sex outside and and in school or not really sex but sexuality. But the challenge with comprehensive sexuality education is the link from education to actual service delivery. And that's very, very important because you can give all the information you, you can to this scale. If they're not able to access the service in the end, then that journey not complete. So we really need to strengthen that gap and also we need to educate and make parents and communities aware to say comprehensive sexuality education is not just learning about sex because as a parent we are thinking now you're teaching my child about sex. I don't want them to learn about sex, but comprehensive sexuality is more than just sex. A lot of it is empowering a young person to be able to make sexual health decisions. So we need those too. Then bridging that gap between education and services and also making communities aware to appreciate what comprehensive sexuality education really is.
Jennie Wetter: So we've talked a little bit about some of the barriers that um, young girls face to me do you maybe want to talk a little bit more about what barriers they have to deal with that when they're trying to access care?
Inonge: I think one of the greatest barriers also is that there is not many safe spaces where girls can actually go and get a service. You expect a girl to go to a facility. What is grandma Ingone who's 50 years old and you are 15 years old and you can queue up with grandma Ingone, that doesn't feel right. You know, like doesn't feel discreet. I'll give you an example again in in one of my field works, so I was talking to one of the government's nurs4es about discreteness and, and, and private service and she told me a very, very sad story. She said one time there was a girl who came, she came for pregnancy tests. And so when she came to see the nurse, still quite busy. So she said, Oh, you know, you take a seat and I'll be with you in five minutes. And so she sat by the bench while there was this other women and for sure within five minutes she came and got her to attend to her. But what she did not do was to, to make that girl sit in the right spot. She asked her to sit on the bench where there are women who had come for antenatal care, so everyone was so heavy. I was like, hmm, she's pregnant. She's pregnant. That's why she's, she's sitting on this bench and before long, the whole village was talking about her being pregnant, she's pregnant, she was waiting at the antenatal care. We sat with her by the bench, you know, and the parents now asking her, are you pregnant? I was like, no, I'm not pregnant. Everybody was asking, are you pregnant? Then they were like, no, pregnancy shows. Well wait a few, a few months and we'll see. And they waited and she was not pregnant. The next things that, oh, she's had an abortion. So you can see how then can a young person go and access the service in such a place when it's not safe. Even just sitting on a bench, people begin to accuse you of things that you're not doing. So we really need to be able to provide this discreet and safe spaces where actually girls can actually come in and get a service and also provide a passiveness as as providers. We should not be biased. We should not be telling young girls to say sex is not for you. Do you know what that means? If you told me I come to you and you told me sex is not for me, how can, as someone who cares, right? And I'll go and ask this wrong boyfriend and say I was taught that sex is not for me and the boyfriend would tell me, come, I'll tell you all about sex and I'll show you how it happens. And that's how you end up having unprotected sex because you, you, you found refuge in this, this way when you went to people who as opposed to really give you the right information, they said this information is not meant for you. So those are some of the, the, the bigger challenges that we faced. Of course there's some things that are being done about it where providers are being, you know, trained with values. Clarification, why you're able to say, look, it's not about me, but it's about this young person who has come. But it's not everybody who is doing it.
Jennie Wetter: So I know that is one of the things that MSI is doing. So what, um, led MSI to look at some of the most effective ways to reach these young women?
Inonge: Yeah, so I'll, I'll give example, uh, an example of Zambia. So in back home, in, in, in Zambia, we, we had a clinic, a very nice, beautiful clinic, which was very spacious and we had nurses and we had all the contraceptive methods there and everything was all happening and we thought we, we had to try it. But young girls, we're not coming. We had adults coming, but young girls were not coming until we followed the journey of young girl who came. We're like, okay, let's follow her journey to try to understand exactly why is it that young girls are not coming, what are we doing wrong? So she came through the gates, you know, talk to the guard, get me in through the reception and got to service. And afterwards we spoke to how was the service and ehhh it was, okay. Would you recommend it to your friend? No. Why not? Well, I got the service, I got what I wanted. But the experience wasn't nice. I came in, I waited for a long time in the reception and every time I was there I thought mommy was going to walk through, you know? And then I was taking inside for counseling with very spacious rooms, with a lot of rooms for counseling. Every time I turned the corner, I thought there'd be someone I know, you know? And I sat down with the provider. She was really nice and she, she spoke to me about contraception, but she was very quick to judge me that I'm having sex. So if you're having sex, here's the best method for you to use, you know? And she showed me all these methods, which were very scary and told me, Oh, this one is a long-term method. This is the best protection for you. I got the method. But the whole experience wasn't good. That's when we realized that we had a problem. We didn't know who an adolescent was. We didn't know how to make contraception appealing to them. And so we went into research mode to find out how then do you want contraception presented to you. And we talked to dozens and dozens of girls and they told us all we want is a discreet service. When we come to a space we want a space, which is a social space where we can find fellow young people whom we can talk to about sex and relationships and have honest conversations. But when we come to your center, the first person you see is the provider, who would tell me family planning, you know, and I'm not planning a family, you know, I just want to have sex and have it safely. I don't, I don't want to to space kids because I don't have any kids. I'm spacing. So we realized that even our language was very wrong. We didn't have the right language that would be appealing to girls. And so we had to change. We really, business as usual was not working. We had to change then how can we make contraception appealing? And so we engaged young, young girls whom we call tin connectors, who when a young person comes into our youth center, that's the first contact, this young phase. And they have those honest conversations and then they're going to get the service from the provider and the youth space. The whole model, which will, which we give birth to is called the dealer model. It came from the young persons themselves and said, we want a space which is bright and nice colors. And so when you come to our youth centers have got the greens and the reds and you know, I, it's a whole nice social space where girls can actually sit and talk and have honest conversations more than just contraception. They talk about hygiene, condom negotiation, HIV misdirection, you know, how does the body work and so on. And then they go out there and get a service. But most of all was that we needed to link contraception to what was really important to the girl and what was important to the girl her aspirations and dreams for her future. And so then it was here is a contraceptive method so that you delay pregnancy so that you can achieve your dream. At some point too, we were saying here is family planning so you can space your children. Right. Okay. And it goes where like that's not my message, you know, but now we're talking about aspirations and dreams and, and being empowered and so girls can now relate to contraception. And we've seen girls now coming into the center because it is so demedicalized when they come they're saying we are not sick. We just want someone to talk to someone who understand what our dreams and aspirations are.
Jennie Wetter: That's so great. And I really like the talk about the importance of language because it changes everything as you noted, right? Going from framing it as not family planning for timing and spacing your kids to what's important in their lives. Um, and that made a huge difference for them.
Inonge: Exactly. Cause you see, if you, you come to me who has kids and you talk to me about family planning and births and spacing my kids, it's what appealed to me because I'm thinking, okay, my son is two years old. I think maybe I won't be ready until two years from now. Then spacing becomes appealing to me. But if I'm 15 years old and you come to me and tell me about spacing, it doesn't make sense. If you tell me to say no, you need to wait. WHO says you need to wait for two to three years for you to be healthy enough to have a, to have another kid, then the uterus to contract, you know, like to contract and you're like I'm 15 years old, I don't have a uterus that needs to contract, you know, so that message is not appealing and I'll say no to contraception. I'll say no to family planning because your language is just wrong. So we need to get the language right. How can contraception be appealing to young people? We need to get the language right.
Jennie Wetter: So let's say I'm a girl and I go to this clinic now, what does my experience look like?
Inonge: So your experience would be something that is really appealing to you that was designed for you and recall that the user centric approach. And with user centric approach you have the people you're designing for in mind, you can design anything without involving the people that it's made for because you will get it wrong. I'll give you a very typical example. So when we came up with a diva model, which was very urban for urban gals, it's, it's very nice and fancy. Even the way we look at contraception. We have these cartoons which speak about contraception. And so we got the brand and took it to rural Zambia. Okay. And we went to see our adolescents in rurals, and then here is a brand for you to actually use contraception. And the girl said, no, this is not for us. Look at this. Cartoons, they've got nail polish. They've got lipsticks, they look like prostitutes. Look, they're wearing boards and they've got phones and so on. No, no, no, no. This is not for us. So you see that brand worked for urban, it did not work for rural. So anything that's user centric needs to have the user in mind. And so again, we have to go back to the drawing board. Who is a rural adolescent, what is appealing to them, what is their expression and what's their dreams? And it was very, very clear that there are two different groups and that made us realize that young people are not homogeneous. The fact that I'm 15 years old does not mean that I'm like everybody else. I'll give you an example. If for example, we were both 30 and were looking for a gym program for weight loss or for, for for just looking healthy, our needs would be different despite as being 30 right? Yeah. Because I'm African, I'll probably be saying, hey men, like women with big bottoms. I want to exercise to give me big bottoms. You know, maybe you've been from the West, you'd be like, no, we went, I want a big bust. Is there any exercise which can make my bust big. But you are both 30 and the needs are different. So what makes you think that the 15 year old is the same? I might be 15 and not in school. I might be 15 and be in rural Zambia ...Yeah, I might be 15 and be in urban. I might be 15 and with a kid. So the needs are very, very different. And so when you're talking about user centric, you have to look at the moment that the girl is at when you're designing for that intervention to be appealing to that young person or else you get it very, very, very wrong.
Jennie Wetter: Absolutely. Yeah. It's so important because everyone has a different life experience and it's so important to focus on the girl and where she's at. So what have you seen the impact be?
Inonge: So what we've seen with the impact from the different interventions that we are doing in Zambia, we've, we've seen very significant growth in the number of girls who are coming to, um, to our centers. So between 2013 and 2018 we've seen a compound annual growth of about 55% of girls coming in. But for me that's not very important. What is really important is the fact that we are having girls walking and saying, I just want to listen to you. I just want to know what hygiene is because this place is safe. Okay. They may come in and not walk away with a method, but they'll come in and get some very impactful information about their sexual health and be able to make very impactful decisions for their own lives, which they can't do at the, at the facility where there's vastness where or where providers are judgmental. So having, um, user centric approaches as meds, um, the youth centers or our approach, very youth friendly, very youth focused. Any young person can come and say, look, I just want to listen. I just want to learn or I want to get a method.
Jennie Wetter: It's so important to have a safe space to go where you can learn and know that they're getting honest information and accurate information. And you know, think about, you know, the story you told at the very beginning about the girl who had the baby and was HIV positive and the baby was HIV positive. She had somewhere to go earlier that could have changed so many things down the path for her.
Jennie Wetter: Here in the U S we're seeing a lot of the states are passing bans on abortion. What does abortion access look like in Zambia, particularly for young women?
Inonge: Um, so abortion in Zambia is legal. Uh, but there are some restrictions. For example, you need three doctors to sign off, um, an abortion service. Um, and, and that can be a challenge. That can be a barrier, but it is provided for in the constitution. So what we do, we still need to do is to make young girls aware, to see it is legal. You can actually access it and direct them to where they can actually get a service. In my experience, what I've seen, when you put all these barriers, it doesn't stop unsafe abortions. It actually increases the rates of unsafe abortion. When you restrict abortion safe abortion because when the girl has decided to terminate, they would do it anyways. You're better off giving them a safe place where they can actually get it done. I'll give another example. I've got lots of examples.
Jennie Wetter: I think the examples are so important for people to relate to.
Inonge: So we have a toll free line, five six zero zero in Zambia where girls can call for whatever information that they need. And so we had the young girl who called and said, um, I've tried to terminate from home because I thought I could not afford an abortion. So she came to our center, um, and we had to complete the, the abortion service. But when she came, it was really, really sad because she didn't have anyone to tell. She said, I can't tell my mommy. I can't tell daddy because as far as they know, I do not have a boyfriend. So how can I be pregnant? I don't know. I don't have anyone to talk to except the toll free line and yourself. So I thought of being part of the procedure. So I, I try and understand how the procedure is done and this girl lay there on the couch in pain and during the procedure because it was very, very painful. But because of our culture background where a woman is not supposed to be heard, so she was crying quietly, you know, like no sound. They were just tears rolling down her cheeks in pain and there was no one to tell her story except to Marie Stopes except to the toll free line. And she went through the procedure and all she was saying, I never have sex again. I'll never have sex again. Because now she was, she know, like the perception of sex was not very bad. It is very painful. It was very, very negative, you know, I just saying, I'll never do this again. But um, due to the good counseling, she, she actually also got them a post abortion family planning method, which was great. But I think the sad thing was even after that procedure, there was no one to go back home to, to tell a story because she was too scared. So can you imagine if we had the banned to this service? If we banned to say look Marie Stopes, you cannot provide this. Where would such a girl go? She is not the only one. She is representing a lot of girls in Zambia. A lot of girls in Africa, a lot of girls globally who needs that support and sometimes they don't have anyone except the toll free line except that provider who has given her that service. So let us not deny the service to young girls. It is their right. We owe to them, we owe it to them. If someone had talked to this girl earlier maybe she wouldn't have gone through all this, but we missed the moments when she needed us even at this very last moment. Why should we deny how to service? It is hard.
Jennie Wetter: Right. I really like your talk about important moments to be there, right? Not Missing these moments and making sure that you are there when you are able to. It's just so important. As we're watching attacks on reproductive health care in the U S and we've seen some of those attacks be exported in US policy abroad, that you're going to have more organizations, more people who are not, who are missing those moments and aren't going to be there and that these girls are the girls who are going to suffer.
Inonge: I would like to talk to policy makers that these policies that we make, they're not for us. They're for this generation that is coming. It's a very, very huge cohort is the biggest cost in history. And if we miss it, we are significantly going to affect the population. So even as we make these policies, let's not think of now, now and, and how many votes I'll get its not about us. It's about these young people. Let us invest in them because the dividend in the, in the cohort is worth the investment. Let's not be selfish and say no, this policy and that policy and so on. Let's think of who really is in need.
Jennie Wetter: So what are your hopes and dreams for the girls in Zambia?
Inonge: My hope and dreams for girls in Zambia... It's very simple. I'd like to see a girl who's empowered, a girl who's able to make significant decisions about her body and her future.
Jennie Wetter: So I always like to end with a hopeful thing. What can listeners do? Um, do you have anything? Like what, what would you like to see people who were listening to this podcast, what can they do to make things better?
Inonge: What what you can do as an individual is to listen to this young girl, to not judge her. The fact that she's come to you to seek help is a big step. So if someone comes to you and says, I need help, there's options out there. If you cannot provide that support, show her where she can get help. It's, it's a simple as that. We're not saying that you need to change your value. Sometimes it's hard to change values and if you can't change your values, at least point them to where they can actually get help so that you don't miss that moment in that girl's journey. Can you imagine this young girl who comes to you and says, how can I have safe sex? And just saying, go away and she goes and does a wrong thing and she gets up with she, she ends up with a disease and pregnancy. I think that's worse than telling her or pointing to the right direction.
Jennie Wetter: Ingone, thank you so much for being here. I hope you enjoy the rest of your time in DC.
Inonge: Thank you. I know I will. I'll do a lot of sightseeing.
Jennie Wetter: Good.
Inonge: Thank you so much for having me.