Unmet needs and demands in the Ciskei

Sixteen year old Bongani is from a rural area of the Eastern Cape better known as the Ciskei. She's near the top of her class at school, pregnant and worried parenthood would prevent her realising her dream of becoming an attorney. Both her parents have died from HIV/AIDS and Bongani has lived with her grandparents since. I asked Bongani what her boyfriend's reaction was to news of the pregnancy. "We met three months ago…"  she said, but tailed off. I got the impression they're no longer together. She looked terribly depressed so I didn't try to clarify. Her grandmother, Lindiwe, told me "a 16 year old mother won't finish school or go to university to study law. I'm 75 and I can’t take on a great grandchild. I just can't, look at me." Lindiwe shrugged her shoulders, sighed and continued, "Bongani is going to have to deal with this herself."  Given Bongani's situation, age, worries and dreams I assumed "deal with this herself" was a euphemism for abortion. I asked Lindiwe how far they'd have to travel for a termination. "It’s over 100 km to the nearest hospital but she's not doing that, she needs to learn from this. She's keeping it." I didn't know whether that was what Bongani wanted but becoming a single parent at 16 doesn't seem like the best way to learn a lesson. Two weeks later I met representatives of Pathfinder International, an organisation operating in parts of the Ciskei involved with youth focussed sexual and reproductive health services. I kept thinking of Bongani.

A rural community in the Ciskei lacking most basic services

A rural community in the Ciskei lacking most basic services

Prior to Pathfinder joining forces with the local Department of Health, abortion services in the Ciskei were largely restricted to the area's few hospitals. In this primarily rural region it meant the closest service provider to some villages could be hours away. For women in some settlements, who are dependent on public transport, reaching a hospital before midday is impossible. By that time overstretched hospitals are unlikely to have availability for further patients seeking terminations that day. One aim of Pathfinder's work is to plug gaps like this where there's an unmet need.

Unplanned, mistimed or unwanted pregnancies, such as Bongani's, are not always due to the lack of availability of sexual and reproductive health (SRH) services. Pathfinder's Andiswa Msuthu explained "we’re working in an area where some people actually believe contraception is the cause of sexually transmitted infections and many people think the number of children you have is down to the will of God." Andiswa’s colleague, Zandi Bakaco, added "Some women believe all types of contraception can cause blood clots in their spines. Also, there's a myth that using contraception today prevents women from being able to fall pregnant ever". The often used phrase "the unmet need" for SRH services gives the impression the problem is only availability but these issues highlight a more basic education problem. To satisfy the "unmet need" for SRH services assumes there's a demand in the first place. 

Pathfinder's youth friendly services

Two women in the Ciskei

Two women in the Ciskei

Pathfinder has enabled six existing rural community health centres to provide additional SRH services, therefore preventing the necessity of long distance travel - for some. Perhaps the most impressive part of their work is the way Pathfinder ensures services are suited to youth. A five day values training program helps clinic staff through a process of identifying and overcoming personal prejudices against abortion and post abortion care. A cross section of staff is trained, from nurses and management, to cleaners and security guards. Zandi tells me "imagine the first clinic employee a young woman meets is the security guard, if she asks him for directions it’s important he's friendly and not judgemental." Prior to training, one medically qualified manager was overheard saying she didn't understand why the SRH services were being offered as they'd simultaneously be providing maternity care in one room and "killing babies" down the corridor. Subsequent to Pathfinder’s training, Andiswa and Zandi have always seen a complete turnaround in attitudes.

The training is culturally aware and each day begins with prayer. They cover the law, fears and the different procedures and services. In addition to the values training, additional youth friendly training is provided. Andiswa explained that when a young girl attends a clinic to see a nurse she's likely to be scared, "The girl might come for an abortion but at first only say she has a headache, it's important to handle youth sensitively so they can access the services they came for".  Unfortunately part of the service providers' role is to find out whether pregnancies result from consensual sex. Zandi told me about a lesbian couple who were both raped by men they knew who lived in the same township. So called "corrective rape" of lesbians by men either thinking or claiming they think rape converts lesbians is yet another shocking reality Pathfinder's programs must deal with. I asked Zandi if the men were imprisoned "No, it was not reported, she wanted to put it behind her".

Andiswa and Zandi were keen to stress the aim is to ensure girls don't need to return for a further abortion and so counselling also covers contraception and longer term options. Many young women in the Ciskei are choosing injectables as they're concerned pills could be discovered by their parents. The youngest pregnant girl to visit one of the Pathfinder assisted clinics is 13. It's inescapable that people are becoming sexually active much younger and this amplifies the need for improved education to prevent the need for terminations later on. Whatever the client's age, testing and counselling for sexually transmitted infections is also offered.

Pathfinder only has sufficient funding to work in one of the Eastern Cape's seven districts. Their work is needed and the partnership with the Eastern Cape Department of Health sounds like a strong successful one. Unfortunately, in a country which has so much talk of empowerment, transformation, skills development, upliftment and constitutional rights, it's tragic that so much is just talk. Promising students like Bongani, whose village does not benefit from a Pathfinder clinic, would be better served through the provision of improved education and health care than many of the existing transformation initiatives - road renaming programs for instance - which although valid do not and cannot impact the lives of rural women in any meaningful way. If ever there were a priority community for improved education and health care services, rural women must be close to the top of the list. Looking at many of the schools and clinics in the Ciskei it doesn't look like this translates to enough action on the ground. I hope Pathfinder can access additional funding to build on its already successful partnership with the Department of Health. Their work should be one of the country's priority empowerment projects. It doesn't seem to be. 

• At their request, I've changed Bongani's and Lindiwe's names.

• Of the 100 articles in this series, at least four more will focus on the work of Pathfinder in South Africa. Please like the project Facebook page by clicking here, to make sure you don't miss them.