Amy Lehman — Sex education, family planning and reproductive medicine in remote areas

I am honored to follow Kristina Graff’s piece about fistula risk as one of the major – and all-too-common – risks of childbirth in sub-Saharan Africa, which in my work in the Lake Tanganyika basin is something I see with awful regularity.

Last year, I witnessed a 16 year-old girl die after experiencing exactly the type of scenario Kristina described:

A teen-aged girl from Wampembe (one of the most remote places in all of Tanzania), with an immature pelvis, in an area with no health care workers at all, suffering from obstructed labor, rides an unstable bus and walks over 120 kilometers.  When she arrives at the district hospital in Namanyere, she is in septic shock, with a dead baby in her body, and a massive fistula has developed between her ruptured uterus and her bladder.  She collapses, and is brought to surgery – performed by an overwhelmed generalist, as there are no Obstetric-Gynecologists in the region.  She has lost a tremendous amount of blood during her awful journey, and there is no blood with which to transfuse her.  There are no proper antibiotics.  There are not enough nurses for the hospital to look after her post-surgery.  There is no critical care.  Just as I walk into the ward, shared with other very young mothers and their infants, the girl dies.

Because Kristina has done such a complete job of delineating the infrastructural barriers woman come up against when trying to deliver a healthy baby, while remaining free of personal and shameful injury, I would like to talk about an issue that is both highly controversial and incredibly integral to a discussion of improving maternal health: sex education, family planning, and reproductive medicine training in general.

As the Touch Foundation has identified, improving the health of societies requires an entire “molecular” framework that includes education.  I see this in terms of both education of healthcare workers, as well as education of girls and women.  In the ultra-rural areas of Tanzania, and in fact the entire Lake Tanganyika basin, women and girls suffer a disproportionate lack of both access to care and access to education.  Here are the areas where girls are married very young, and begin having children when they themselves have not yet physically matured.  In the basin, it is not uncommon to see girls having children beginning at age 14 – and then by the time they are 35 or 40 – they have had multiple pregnancies, have multiple children (and experienced the deaths of a number of those children), suffer from fistula, uterine and/or vagina prolapse, urinary incontinence, severe arthritis and spinal trouble, and many other disorders and diseases resulting from unremitting pregnancies and births.

We have partnered with organizations like The Primary Health Care Project Lake Tanganyika which provides counseling on family planning as well as access to contraception to the girls and women who live in remote Lakeside villages in Rukwa region.  These sorts of interventions can prevent deaths like the one I described here, as well as the scenarios described in the previous blog posting, by empowering women to have more control over their reproductive lives in general.

This is an upstream, public health intervention, which is both effective and inexpensive.  And this is control that is desperately desired by women in the region, who in the absence of this access, often take their own lives into their hands by ingesting herbs which cause miscarriage, or attempt abortions using dirty tools – even sharp sticks – or other even more desperate measures.  Which, again, results in tragic and unnecessary death.

Acceptance of family planning and reproductive health in these rural areas is far more widely accepted than one might imagine.  The religious and ethnic make-up of women along the lake is diverse.  There are Christians, Muslims, Animists.  There are ethnic Congolese, Burundians, Zambians, along side Tanzanians.  And most women agree: they need more control over their bodies.  For this reason, The Lake Tanganyika Floating Health Clinic is initiating new partnerships with U.S. and international organizations like the Midwest Access Project and Ipas to develop curricula for local health care providers on how to expand sex education, family planning, and reproductive health access to the region, as well as to respond to Obstetrical Emergency.

In the basin, family planning is not a political issue, but rather one of life and death which touches every girl and woman, and indeed their entire families.

Amy G. Lehman, M.D., M.B.A,  is the founder of the Lake Tanganyika Floating Health Clinic. The Lake Tanganyika FHC is an international organization whose mission is to address the problem of health care access for isolated communities in the Lake Tanganyika basin/Great Lakes region in Central Africa.