One thing I have discovered is that nothing could more encourage my feminism and my outrage at the dire state of women’s reproductive health than living in Rwanda (I am tempted to say “living in Africa” because I suspect my indignation would be similar across the continent, but as my experience is here, we’ll stick with that). I work with the only provider of sexual and reproductive health (SRH) services in all of Rwanda (according to UNFPA) and I have been a witness, directly in my activities and indirectly through reviews of programming, of the absolute lack of quality services, of information, of anything.
I spent last night at the home of my best friend, Nadine’s, cousin. His wife, pregnant with their fourth child, died over the weekend, while her husband was stationed in Darfur. Yesterday marked the final day of mourning, during which the extended family and friends congregate at the deceased’s house to support the family members before the burial. She was in her early thirties, already a mother to three girls aged 12, 8 and 5. This fourth baby was their first boy. She had had a difficult pregnancy, primarily due to extremely elevated blood pressure. Her primary care clinic determined it was necessary to have a c-section, despite the complications that would arise for the premature infant. They sent her off to the best hospital in the city, where she was told she needed transfer papers in order for them to proceed with the procedure. She took the two mini-buses back to her clinic all the way across the city. They were so concerned about her condition that they considered doing the c-section at the clinic, but decided against it due to the lack of incubators. Back she went again, alone, to the hospital, papers in hand. On her way up to the ward to be admitted, she collapsed and fell into a coma. This young woman and her son died because of a couple of papers. The bureaucracy involved in obtaining health services here is mind-boggling. The paper trail exists at home, too, but the consequences are so vastly different here.
I’m alternately depressed and energized by the state of reproductive health here. Depressed because there is so little I can do, because it’s engrained – no matter what leaps and bounds have been made in progress for women’s rights and equality, women’s health issues, here as everywhere, are not a central concern. Maternal mortality is still high at 750 women per 100,000 live births. The HIV prevalence for women is estimated at 3.6% versus 2.3% for men (regardless of whether I think the statistics on prevalence are correct, there is a clear feminization of HIV/AIDS in Rwanda as in the rest of Africa). The last DHS found that 80% of married women reported recent spousal abuse. 70% of births occur at home, and 61% of births occur without the assistance of trained health personnel. The total fertility rate remains above 6 children per women per lifetime. 29% of women are illiterate, and few women have received above a Primary education. These are determinants for poor reproductive health – anyone in the field is well aware of the connections between wealth, education, fertility and overall reproductive health status. Poorer and less educated women bear more children in shorter time frames, are more likely to die from a pregnancy-related complication, and are less likely to receive ante- or post-natal care. Their children, especially their girls, are more likely to suffer malnutrition and less likely to receive an education; they are statistically more likely to die before they reach their fifth birthdays. It’s a nasty and preventable cycle, and seeing it in action in Rwanda is heartbreaking. It’s for this reason that I’m energized at the same time as being outraged – there is so much potential for improvement. Many women here want change. They’re becoming more aware of their rights, particularly to education and to reproductive health, and women are beginning to demand change. It’s heartening to see more and more young women speaking out against the conditions that have oppressed their mothers and grandmothers. More and more young women are finishing secondary school and going on to university. More and more young women are seeking access to contraceptives and family planning information, and are actively involved in protecting themselves against unwanted pregnancy, unsafe abortion and HIV. Women are becoming actors and participants in their own reproductive lives, rather than remaining passive spectators as their lives unfold around them.
I spent two days last week in a training organized by my organization and funded through UNFPA (the UN Population Fund, the only UN body to focus specifically on population activities and the importance of reproductive health). The first day’s training was on the minimum initial service package (MISP) for reproductive health interventions in emergency situations (refugee camps, conflict zones, etc), and the second day focused on sexual and gender-based violence, specifically in emergency situations. Old information to me as the MISP was something I’d researched quite a bit while writing my honours paper and prior to arriving here, but interesting to see in a new light, especially as for the majority of attendees, this was a whole new aspect of disaster management and response. A few staff from ARBEF was there, as well as several representatives from different NGOs in Kigali, but the vast majority were Disaster Response representatives from districts around the country, people who had little to no training on reproductive health issues. I was sitting in a room full of well-educated and well-spoken Rwandans, roughly evenly divided by sex. And yet, it was still primarily the men who were speaking. And the comments being made demonstrated exactly why training on GBV is so necessary in Rwanda. Comments about what leads to a woman being sexually assaulted, what kind of acts constitute ‘violence,’ and when and whether women have a right to refuse sex. People say the same things in Canada, too. But women here have so little protection, legally or socially, and it’s largely because of a culture that treats women as less. This isn’t to say that women aren’t respected, or that all men treat all women with contempt, because I have seen a lot that suggests the very great respect that many men have for their mothers, sisters, wives and daughters. But there is a culture that emphasizes the role of men as being dominant over women; the patriarchy is alive and well in Rwanda. I’m not criticizing Rwandan culture, because I think there is a lot to be celebrated about it. At the same time, change needs to happen at all levels, and needs to come from men as well as from women. It’s interesting to see the winds of change for women’s reproductive rights starting to blow here, beginning with a whisper of a breeze. Hopefully it will build up to a windstorm.
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