In modern industrialized societies, women continue to encounter stigma and stonewalling when they seek out information about family planning and contraceptive care. But in developing nations, particularly in Malawi, a predominantly rural country in southeastern Africa, the taboo surrounding sexuality encompasses the country so completely that even women don’t believe teenage girls should learn about sexual health. This has created a women’s health crisis: according to the Malawian government’s Millennium Development Goal (MDG) 2014 end survey, 31.3 percent of women in their early-to-mid twenties had at least one live birth before age 18. At 157 births for every 1,000 Malawian female adolescents, the teenage birth rate in Malawi is more than triple the international average. The percentage of Malawian women ages 15-24 infected with HIV is one and a half times greater than that of their male counterparts. Every hour, around 34 young African women become infected with HIV.
Source: Population Services International
These are grave statistics, but the Malawian government is making efforts to help women through improving the accessibility and quality of rural health care and creating legislation that promotes gender equality and protection of women’s freedoms. However, even if Malawian law upholds female empowerment, this will not significantly change a traditional religious culture that can prevent women from using contraception or family planning. Because women’s reproductive choices are decided exclusively by men, rural women in particular become economically dependent on their husbands, and are sometimes forced into early marriages, which further diminish women’s opportunities for receiving the health treatment and counseling they need.
In order to prevent sexual discrimination, harassment, and violence against women, Malawi’s Parliament passed the landmark Gender Equality Bill of 2013. Anita Kalinde, the country’s Minister of Gender, Children, and Social Welfare, explained that the bill seeks to “eliminate uneven distribution of opportunities, which had existed for many years.” Another sexual health policy cornerstone is the Malawi Family Planning Costed Implementation Plan (FP CIP), which the Malawian Health Ministry released on September 16th. Effective from 2016 to 2020, its primary goal is to increase usage of modern contraceptives from 33 percent to 60 percent by 2020, and prevent roughly 2.2 million unintended pregnancies. The total cost of the plan is $94.6 million, and will cover problem areas from access to contraceptives and family planning, to improving training and empowerment for health workers.
Policies such as FP CIP can help improve accountability at the federal level to ensure laws are benefitting local health clinics across rural Malawi. According to Dr. Julitta Onabanjo, East and Southern Africa Regional Director of the United Nations Population Fund (UNFPA), leaders must be held accountable for the work of organizations designed to work with young people, who “don’t have a voice [and] are not empowered.” Focusing funding on more comprehensive health worker training will significantly increase the quality of sexual health counseling for female patients, and also create a more compassionate health culture, which Malawi’s health clinics have tended to desperately lack.
According to periodic reports, medical staff at Malawian clinics, including women, were often dismissive towards younger female patients. Nurse Blessings Sonkhanani, who serves at Namwera Health Center in Malawi, described workers’ treatment of young women as “not friendly” and “judgmental.” When teenage girls asked how to obtain contraception to prevent unplanned pregnancies and STIs, the health workers told them to only look into such matters once they were old enough to be married and start a family.
Supporters of Safeguard Young People, a health clinic in Malawi that seeks to increase women’s access to reproductive health care
In order to change the culture around female health care, the Malawian government has partnered with and accredited more local health clinics to make health education and resources more accessible to young women. They focus in particular in the communities with known high rates of adolescent pregnancy, child marriage, gender-based violence and school dropouts. Safeguard Young People is one such health clinic that seeks to break the convention of poor treatment of women at health clinics by improving interactions between health workers and young women. Safeguard tries to create a welcoming environment that will encourage young women to make the long, inconvenient journey to its clinics. Such methods include providing spaces or hours of operation specifically for young people, and offering a variety of services such as HIV counseling and testing, treating STIs, and family planning.
Safeguard’s friendly clinic approach has been quite successful: in 2014, more than 395,000 people between ages 15 and 24 visited their clinics in the six different districts they operate in. The high volume of visitors to these health clinics, and the fact that more than 100 such facilities have received federal accreditations in Malawi, incentivizes more clinics to upgrade their quality of treatment.
Safeguard’s and similar organizations’ effects are already bearing fruit. According to Malawi’s Millennium Development Goals (MDG) report, 58.6 percent of women ages 15 to 49 in a sexual partnership use, or have their partner use, a type of contraceptive. However, these numbers do not mean that the contraceptive access or STI problem has been solved in Malawi: nearly 20 percent of fertile Malawian women want to use family planning strategies but still do not have access to contraception.
In order to decrease its HIV/AIDS prevalence and high teen birthrate, Malawi could look to Thailand. Thailand’s goal is to eliminate new child HIV infections by 2016. By providing lifelong antiretroviral medicine — which combats viruses such as HIV — and free antenatal services to all pregnant women in Thailand diagnosed with HIV, as well as HIV medication to children throughout infancy, Thailand is well on its way to achieving its target. Nearly 95% of HIV-positive pregnant women received antiretroviral medicines to reduce the risk of HIV transmission and almost 98% of their babies were born HIV-free.
Thailand’s Parliament is also reviewing a draft law to reduce the rate of teen pregnancy and increase female teenagers access to contraceptives. Since abortion is illegal in Thailand, this preventative policy is the next best option for many young women in the country. If passed, it would grant adolescents access to sexual and reproductive health services, mandate comprehensive sex education in all schools, and encourage pregnant students to continue their schooling.
If Malawi were to set ambitious goals for its health policy as Thailand has, in the long term Malawi could experience miraculous success similar to Thailand’s against HIV prevalence. Although Malawi’s HIV prevalence is tenfold that of Thailand’s, and the stigma against contraceptives and family planning is deeply entrenched, if Malawi continues gradually shifting to a more broadly accepting sexual health culture, HIV and teenage pregnancy rates will witness a promising decrease.