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Pathfinder Field Journal
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Awakening: Challenges and opportunities in Gwoza
Nigeria: April 1, 2009
My October trip to the heart of Africa—Nigeria—was nothing like previous trips I have taken. On October 2nd, 2008 I left behind the snow covered peaks of the Andean mountains in my home country of Ecuador, with Abuja, Nigeria as my final destination. Upon invitation from my Nigerian Pathfinder colleagues I took this trip to provide assistance with the monitoring and evaluation exercise of one of our maternal care projects. I was excited and honored to be part of a group of such committed and knowledgeable professionals. Our objective was to conduct a critical analysis of the project’s successes and challenges.
To start the process, just few hours after my arrival after two days of travel, I met with the local team, composed of Dr. Sada Danmusa, Associate Director of Programs, Kaduna Office and Mrs. Jumoke Azugo, Monitoring and Evaluation Officer, from Pathfinder’s Abuja Office. Our agenda was to conduct a joint review of the objectives and expected outcomes of our trip and to finalize logistical arrangements. After productive discussions we declared ourselves ready to go.
In the early morning of October 5th we began a 10-hour drive from Abuja to Maiduguri, the capital city of Borno State (located in the northeast region of Nigeria). During our drive, I thought to myself how lucky I was to be part of this journey from the central to northern region of this beautiful country, which like mine is rich in tradition and culture.
 The 10-hour drive, though long, was truly a gift—I was offered a glimpse into the ordinary lives of men and women of Nigeria. I observed them working shoulder-to-shoulder on their land, caring for their subsistence. Some of the land was lush and green, not only as the result of hard work but also thanks to water access; in other areas without water patches of land were not as productive despite the hours of labor. It was painful to think of the consequences that a season without crop production would surely have for family incomes. I must also note that it was not uncommon to see children working along with their parents, and that pregnant women were not exempt from the labors of food production.
Reflecting, I felt there were many common historical realities in Ecuador and Nigeria. In Ecuador as in Nigeria, historically large families were expected; pregnancies occurred early in a woman’s life and frequently thereafter. Pregnancy and delivery were perceived to be natural events rather than medical. In Ecuador, and many other countries of the world, Pathfinder International along with local NGOs developed and implemented contraception/family planning community outreach programs and created cadres of medical providers who could offer quality reproductive health services. Over the past several decades, access to much-needed reproductive health services has increased. These reproductive health efforts have contributed to increasing contraceptive prevalence and decreasing maternal and neonatal mortality. So, while traveling through a different and distant country and seeing challenges, I was reminded that initiatives implemented over two decades ago have proven fruitful and I began to dream about the same possibilities for Nigeria becoming a reality.
Although the journey to Mauduguri was long, it was exceptionally pleasant and engaging; the change in landscape, the periodic call to pray together, and a rich dialogue with my Nigerian colleagues transformed a potentially arduous trek into a pleasant and very informative trip. I was looking forward to visiting Gwoza, meeting with Pathfinder’s partners and collaborators, and learning more about the challenges and successes of one of our programs. Anticipation grew when Dr. Sada told me that Gwoza was right behind a mountain visible from the road—he was right, in just 30 minutes we arrived in Gwoza.
As soon as our team arrived, we were ushered into the Local Government Agency headquarters where more than 40 citizens were awaiting our arrival. It was an overwhelming feeling—it was a very humbling experience to hear through a translator the expressions of gratitude towards the organization I was representing, “Without Pathfinder’s interventions the men and women of this community will not be enlightened with information on safe motherhood” or “Without Pathfinder our women will continue to die” were some of the feelings expressed by local authorities and religious leaders.
Dr. Sada Danmusa, speaking for all of us, thanked the group for their commitment and interest in supporting Pathfinder’s initiatives and most especially the safe motherhood work. He acknowledged the time they took to travel from distant communities and hamlets to meet us and the wonderful opportunity this provided us to learn from local community workers, health providers and authorities—including religious and traditional leaders.
During our visit we listened to the men and women of this community, the health peer educators and moblizers, describe their outreach strategy—which is simply using every opportunity they have to disseminate safe motherhood health messages. Indeed, they bring it up during conversations after religious services, they conduct home visits, they carry their message to public events and at the market place—there is not a forbidden time—Pathfinder has empowered them with information and they are going to share it!
Some providers testified that indeed more women are attending prenatal care. “Their husbands are coming along with their women” was reported by a midwife. “They are coming early in their pregnancy and have multiple visits” was reported by the maternity matron. However, despite a positive change in behavior during the pregnancy, we continue to face challenges when it comes to dealing with obstetric emergencies. Women arrive too late in an obstetric emergency. Providers said the communities often “wait and wait until the patient is not in good shape” and the sad thing is that “sometimes there is nothing we can do.” Providers’ testimonials on women, their husbands, and extended family challenges when it comes to emergency obstetrics were numerous and wide-ranging. Difficulties in obtaining transportation (of any type) to transfer women from the community to a health facility ranked high on the list. Even when transport is available, terrible road conditions often create another big hurdle for women and their families.
Travel distance cannot be measured in kilometers alone. Road condition and the season of the year are important factors when making a decision to transport women in need of emergency obstetric care. In addition, the decision to move a woman from the community to a health facility is a complex and collective process, one in which (as I was told repeatedly) tradition and religion weigh heavily. My Nigerian colleagues and the providers who were interviewed acknowledged the numerous hardships they face in increasing access to safe motherhood services. At the same time they referred with great enthusiasm to community champions who have served as catalysts for behavior change. One such champion among the many we found is the head of the National Union of Road Transport Workers who has agreed to provide a driver when an obstetric emergency arises.
Our two-day visit to Gwoza came to an end on October 7th. The following day continued our journey and to carry on a similar process in another community in Kano. But before closing the visit to Gwoza, my Nigerian colleagues and I made time to reflect on the highlights of the exercise—we concurred that although much has been accomplished there is still much to be done. We felt reenergized and moved by the enthusiasm and commitment expressed and shown by the community workers, health care providers, local authorities, and religious leaders.
The next day, we moved on as I continued my more than month-long journey throughout this amazing country. But my experience in Gwoza continues to stay with me as an example of all I saw during that time. What a privilege for me to be hosted by a community of exceptionally warm and generous individuals. I was humbled by the experience. I will be forever connected to this small community located in the northeastern corner of Nigeria and look forward to a time when women will no longer face the challenges they do today.
Video: Strengthening Reproductive Health in PNG
Papua New Guinea: January 8, 2009
Cody Swift, a Pathfinder supporter, traveled to Papua New Guinea in 2008. Watch a video he created about Pathfinder's work. Learn more about Pathfinder in Papua New Guinea.
Photos from the field: Bridgit's png Album
Papua New Guinea: Friday, December 19, 2008
Click on the image below to see images from Bridgit's recent trip and learn more about Pathfinder's work in Papua New Guinea.
Photos from the field: Amy's Nigeria Album
Nigeria: Thursday, October 16, 2008
Click on the image below to see images from Amy's recent trip and learn more about Pathfinder's work in Nigeria.
"Sensitive and challenging issues"
Nigeria: Thursday October 16, 2008
 During a recent trip to Nigeria, I had the pleasure of working with my Nigerian colleagues and one of our grantees to learn more about the work we are doing in northern Nigeria in preventing unwanted pregnancies and ensuring female adolescents receive proper care if they have had an unsafe abortion through our Youth-Friendly Postabortion Care Project (YF PAC). Unsafe abortion is a leading cause of death among female adolescents in Nigeria, contributing to 72 percent of all deaths among women under 19. Because of the social stigma and legal restrictions around abortion, women often go to traditional healers or other types of unskilled providers in unsanitary environments to terminate a pregnancy. In most cases, the result is death or the need for emergency care, which can sometimes lead to sterilization and other long-term health problems.
Prior to my trip, my Nigerian colleagues briefed me on how to approach the community on sensitive, and sometimes challenging, issues such as abortion and postabortion care. While I was really looking forward to meeting with community members and hearing their voices first hand, I was also apprehensive about potentially creating misguided perceptions. In parts of Nigeria there is some skepticism toward the western world. For example, during a recent polio vaccination campaign in Northern Nigeria, rumors started surfacing that the vaccinations provided by western countries contain substances that can cause sterilization. With the involvement and support of the religious leaders, the vaccination campaign was able to continue.
 To ensure support within communities for YF PAC, Pathfinder partnered with a local organization, Women Reproductive Health Center, to implement the project. Over a 3 day period (June 23-25th), Dr. Hassan, the president of the organization, generously guided us through the community to meet with community and religious leaders, a principal of a secondary school, and the service providers at the facilities where we have trained doctors and nurses and equipped facilities to care for women, including adolescents, who come in with complications from an unsafe or spontaneous abortion.
It was obvious to me, through my interactions with Dr. Hassan and the community, that he and the staff of WRHC have established very close and trusting relationships with the community that has allowed them to open doors and discuss sensitive issues. The first day I arrived at the office of WRHC Dr. Hassan was on the local television channel explaining what abortion and postabortion care meant and the differences between spontaneous and induced abortion. He also discussed the risk involved with unsafe abortions and the need to support youth when they encounter such consequences. As I heard from the peers we are working with—who are responsible for educating the youth and identifying emergency situations and making timely referrals—it is not uncommon for adolescent females who become pregnant outside of marriage, or who have an abortion, to be ostracized from the community and their families.
June 23rd
The first day of our excursion, I toured one of the WRHC clinics and attended one of the antenatal health care talks being given. The room was filled to capacity with pregnant women and their children. My colleague was kind enough to translate for me the discussion that day on the importance of antenatal care and delivering with a skilled provider, as well as the importance of healthy timing and spacing of children. In another section of the room there was a group of women watching the television discussion Dr. Hassan had given on abortion and postabortion care.
June 24th
 The second day, we visited the community leader, religious leaders and other important community members of this predominantly Muslim community. We were graciously greeted and I respected their customs by not shaking the men's hands, but tried to compensate with a smile. We entered a dark but comfortable room with the only light coming from the small doorway we had just entered. One of the WRHC members and I were the only women present. The room was filled with men sitting on the floor, peering through the doorway and sitting on the surrounding seats. It was evident that these men in the community have an influential role and are the main decision makers.
Dr. Hassan took the lead in explaining our visit. I was particularly interested in hearing from them if they thought unsafe abortion or pregnancy among the youth were problems in their community, but I was reluctant to ask this question directly. After several attempts at this question, the community leader finally explained to me that one of the biggest problems their youth face in the community is unemployment. He then went on to explain that this leads to too much time on their hands and risky behavior. When unmarried couples do become pregnant, the community leaders encourage the youth to get married. Before I left the meeting one of the men asked me what the purpose of my visit was. I was not sure whether this question indicated suspicion, mistrust or just simple curiosity. I responded simply that I was there to learn from him and what his community is doing to address the issues concerning their youth. He gave an approving nod showing his satisfaction and we parted.
June 25th
 The following day we met with the principal of a secondary school. Through his support, Dr. Hassan and his staff have been able to hold discussions during organized parent-teacher meetings. These meetings address the issues of parents rejecting their children because of unwanted pregnancies and how forced marriage denies their children an education. By talking from a religious point of view—such as Islam’s support for child spacing, which can prevent unwanted pregnancies—the community is more receptive. The message to PTA members has emphasized that parents should be supportive of their children no matter what the problem is and discussed the importance for parents to listen to their children (parent-child communication) and let children discuss their sexual development.
There is still a lot of work to be done in preventing unwanted pregnancies among youth and avoiding unsafe abortions. I was reminded by the fact that in order for such highly sensitive issues to be discussed in these very religious societies, it must be done in a way that is appropriate to the religious and cultural backgrounds of the particular communities and allows time for the development of a trusting relationship. Discussing issues about child spacing in the context of Islamic religion, which also supports child spacing, followed by discussions on preventing unwanted pregnancies with married couples, can open doors to more sensitive discussions for youth. It is important to recognize that developing these relationships takes time but, in the end, it is one of the most effective ways to reach out to the community to address such challenges.
Photos from the field: Nancy's Ghana Album
Ghana: Friday, September 12, 2008
Click the image below to see images from Nancy's recent trip and learn more about Pathfinder's work with youth in Ghana.
"Interesting...complex...challenging"
Nigeria: Thursday August 28, 2008
 When I tell people the work I do with Pathfinder International, they often ask me what Nigeria is like. My response is usually short and general with statements like "it is interesting...complex...challenging." However, if I sense the person really wants to hear more, I go on to tell them that I have spent the last five years working on projects in Nigeria and have come to love the complexity, cultural diversity, spontaneity, and landscape of the country. With the largest population in Africa and a land mass slightly larger than twice the size of California, Nigeria has over 250 languages and distinct tribes and a landscape that stretches from the tropics reaching the Atlantic Ocean in the south to the Sahara desert in the north.
Lagos city in Southern Nigeria is one of the top 10 mega cities of the world, with a population just over 13 million. Life in Lagos drastically contrasts to the lives of other Nigerians that take you down narrow foot paths or dirt roads for miles without anything in site. You experience the diversity of Nigerian cultures when you drive through the capital, Abuja's city streets and traffic patiently stops for nomadic Fulani's to allow their cattle to cross or, when visiting Kaduna state, you see Muslim woman covered from head to toe passing women wearing jeans and a short sleeve shirt.
While there is much to love about Nigeria, Nigeria still faces one of the highest rates of maternal deaths in the world. Not receiving the immediate care needed from complications that arise during pregnancy and delivery, as well as unwanted pregnancies that lead to unsafe abortion, are the main contributing factors. Pathfinder Nigeria's current programming portfolio includes projects that work to reduce the maternal and child mortality rates. Overall family health is being improved through creating awareness about the importance of healthy child spacing, preventing the transmission of HIV from mother to baby, identifying risk factors during pregnancy and recognizing emergencies and improving access and the quality of services for youth, women, and men at the community and facility level.
I have travelled to many clinics in Northern Nigeria on antenatal care or vaccination day. The facilities are generally crowded and, what is always surprising to me is how young these mothers are with their second or third child. Once on a plane trip from Nigeria to London a 37-year-old Nigerian woman sat next to me on her way to a conference for work. Noticing I was married, she asked how many children I had. When I told her I didn't have any she asked how old I was. I told her I was 34. She gave me a slight smile. I wasn't sure if it was because she felt bad for me or didn't know what to make of my situation. Despite being on birth control, she told me, she was pregnant with her 7th child. She had tried to terminate the pregnancy, but had been discouraged by the health care provider. We looked at each other, both recognizing how different our circumstances were.
"The visitor has great big eyes"
Ghana: Friday, August 8, 2008
 Last week when talking with a member of Pathfinder’s Board of Directors, he cited the organization’s reliance on nationals, rather than expatriates, as one of its unique strengths. A Ghanaian and former Pathfinder Country Representative himself, he cited a Ghanaian proverb to illuminate his point: “The visitor may have great big eyes; he sees but does not comprehend. The visitor has great big ears; he hears but does not understand.” This proverb immediately resonated with me as a visitor to Ghana, but its true meaning and its relevance to Pathfinder’s work became evident throughout my week in the North.
My two Pathfinder colleagues, Moses who is the Reproductive Health Program Manager for all the Pathfinder Ghana activities and John who is the Project Coordinator of the Comprehensive Abortion Care (CAC) Project, are both nurses, MPH degree holders, and former professors at a nursing college in the Upper East Region. They were raised, educated, and began their professional life in Northern Ghana. Their vast knowledge and obvious passion for improving the health of women in the three Northern regions is invaluable in implementing Pathfinder’s work. Moreover, their cultural awareness and ability to fully connect with the nurse/midwives carrying out the work is undeniably the strongest aspect of Pathfinder’s CAC programming.
The last facility that we visited in the Upper West was plagued by many of the same challenges as the other facilities: staffing shortages, lack of proper equipment and materials, low knowledge of infection prevention, and poor recordkeeping. But, unlike the other facilities, the nurse/midwives we encountered at our last stop were clearly reluctant to accept the introduction of CAC at their facility. After a full day of tirelessly completing the facility assessment, Moses, John, and I sat down with the midwives of the maternity ward to further discuss the project and get our last few questions answered. We sensed it earlier, they finally said it: “I won’t participate because of religious reasons.” Although it was actually a surprise to me that we only encountered this kind of reluctance toward the end of our week, I nonetheless had no idea what to say to the midwives expressing their concern. The facts and figures related to women’s health and the issues surrounding abortion are so vastly different in Ghana than in the United States, that any response I could give would surely be off the mark. Moses, without skipping a beat, began to further explain the CAC project, emphasizing that it is a comprehensive program aimed at saving women’s lives by working to prevent unintended pregnancies through family planning provisions, training midwives to provide treatment for the complications from unsafe abortion, and—most of all—providing a place where women and even girls can come to receive counseling when faced with an unintended pregnancy. Moses went on to say that the project is not intended to encourage elective abortions, and explained the provisions under Ghana Health Services that require facilities to provide comprehensive abortion care in an effort to decrease maternal mortality.
 John supported the nurses in saying, “We are all religious people.” He made it clear to them that their concerns were respected, but that judgments should not be made without fully understanding the work. Moreover, John emphasized that “everyone can do their part” to save a life; sometimes this takes shape through medical procedures, but most times it takes shape through informed and non-judgmental counseling of women who have nowhere else to turn for help. I could see the midwives beginning to see the larger context of the program and getting beyond their initial preconceived notions of what we were there to do. Since the program relies almost entirely on the full participation of the midwives, it was necessary to gauge the feelings of each midwife in the hospital. A meeting was set for the next morning.
It was amazing for me to see that every midwife, most of whom had the day off, showed up to discuss the program. Moses and John again went through each and every part of the program, emphasizing the important goals we hoped to achieve and the reasoning behind each of the five components of CAC. The midwives were concerned about the legality of abortion and many, in fact, were not aware of the law legalizing elective abortions performed by trained personnel at registered health facilities. The midwives described the evident need in the community and the women they had seen coming to the hospital with complications of unsafe abortion. Now they rely on the doctor to treat these cases, often times leaving the woman to wait a long time to receive services. Led by Moses and John’s intuition, the conversation began to shift to a discussion of the materials and refurbishments that the facility needed to house the CAC program. The midwives, individually and as a group, better understood the program, their role, and the potential impact on their community.
I believe that this conversation could never have taken place with non-Ghanaian staff leading Pathfinder’s effort. The level of cultural understanding needed to navigate such a sensitive topic could not be matched by an expatriate, and without such an understanding, the project would have been plagued with problems and confusion throughout. Pathfinder’s reliance on nationals is unique. Many US-based organizations support US citizens to facilitate their work abroad. But I am truly grateful that I’ve had the experience to work for an organization that values and supports local professionals to carry out its work. I have seen that this organizational choice allows greater access to the community and—ultimately—a deeper impact through its programs.
"We Don't Have"
Ghana: Thursday, August 7, 2008
 Tumu District Hospital in the Upper West Region of Ghana has one practicing doctor to serve the needs of a population of over 90,000 people. Those 90,000 people rely on that one doctor, who also serves as the hospital’s medical director (an administrative role), to perform every procedure where a doctor’s care is needed, including cesarean sections and most cases of complications from unsafe abortion. Working virtually around the clock, while shuttling himself between two health facilities, I dared not ask what happens if he is out of town, sick, or otherwise unavailable.
I have spent the past week working with Pathfinder’s Reproductive Health Program Manager, Moses, and the Project Coordinator, John, on facility assessments for the Comprehensive Abortion Care (CAC) project. Facility assessments are the first step after acquiring funding in implementing a project based at a hospital or health center. Pathfinder has ongoing CAC projects in the Upper East and Northern Regions and new funding has allowed for the expansion of the project to the Upper West Region—considered the most remote and underserved region of Ghana. Our task was to assess the facilities ability to house Pathfinder’s CAC project, consider the communities’ need, and determine the necessary level of intervention. Moses, John, and I visited each of the four main hospitals in the region using an elaborate assessment tool to gather information relating to virtually every aspect of the hospitals’ workings: client volume and range of services provided; recent staff trainings and acquired skills; record keeping; up-to-date protocols, as well as the availability of various rooms, equipment, medicine and family planning commodities. The assessment tool includes a rating system where a mark of 1 means inadequate or not present, 2 means adequate, and 3 signifies good. At Tumu, it quickly became clear, as our pages began filling with row after row of 1s and most of our questions were answered with a simple, “We don’t have,” that this hospital was the most poorly equipped of the ones we evaluated and the most in need of support.
 The staffing shortages, in every corner of the hospital, are what struck me as the most devastating. There are five midwives to run the maternity, labor, and antenatal wards for three shifts, 24 hours a day, seven days a week. There is rarely more than one midwife available at a time to see to the hundreds of women who come each month for services. The midwives of the hospital not only attend to all pregnancy-related health issues, including deliveries, they also act as the access point for the communities’ contraception needs as well as HIV/AIDS counseling and testing including prevention of mother to child transmission. There is one nurses’ aide to assist the midwives and no administrative workers for the entire maternity ward.
In such an environment, it can be easy to give up. However, the midwives ability to forge ahead and continue the daily struggle of providing care for the women of their community is remarkable. Pathfinder’s CAC project relies heavily on the midwives to carry out four of the five components of the program (pregnancy counseling, family planning, treating the complications of unsafe abortion, and elective abortions); it’s possible to view the project as an additional burden for these midwives. And yet the midwives understand, better than anyone, that the training they will receive and the comprehensive care they will carry out will save the lives of the women in their communities.
Also, the care and concern with which Moses and John, who are both nurses themselves, carried out the facility assessment was remarkable and no doubt contributed to the positive and hopeful attitudes of the midwives. Working from Pathfinder’s experience in the Upper East and Northern Regions, they collaborated to find ways to implement the much-needed CAC project in the context of this struggling facility. Where I saw pages and pages of 1s and heard “we don’t have” after “we don’t have,” Moses and John saw small successes where they could find them and innovative ways to overcome massive challenges. In various publications, we often say, "Pathfinder works in remote locations, under the most difficult conditions, serving the most vulnerable people." After traveling by dirt road, seeing women walking some 12 miles to and from the local market to sell their foods, and finally meeting the one doctor and five midwives serving over 90,000 people, I know this statement to be true. What I learned today is that Pathfinder is able to do this because the determination, creativity and hopefulness of its staff and partners who are able to seek out solutions and solve problems under the most difficult circumstances.
The STruggling Mother
Ghana: Friday, August 1, 2008
 One of my first days in Accra I was stopped by a street artist enthusiastically selling his paintings to unsuspecting newcomers like myself. Of course I was a perfect target and ended up with one of his paintings as my first souvenir from Ghana. It depicts a woman carrying both a large load on her head and a baby on her back; this scene, a favorite of Ghanaian souvenirs, is commonly referred to as “The Struggling Mother.” I did not know it at the time, but this scene has become a symbol of my time in Ghana and reinforced to me the importance of Pathfinder’s work.
Motherhood in Africa is vastly different from motherhood in the US or other developed nations. The image of the struggling mother is not one from years past conjured up for the sake of tourists; everyday I see women carrying huge loads on their heads either vending right there on the street or walking to the market with babies of all sizes strapped to their backs. There is no such thing as maternity leave for these women who struggle each day to raise their family and earn a meager living; they give new meaning to the term “working mother.” On average, women in Ghana have four or five children. For the poorest fifth of the country whose access to family planning is limited, this figure jumps to six or seven children per woman, staggeringly high in a country as economically and politically stable as Ghana.
Although fertility rates are commonly used as theoretical benchmarks in development work, each pregnancy and childbirth for a Ghanaian woman represents not only an addition to her family, but also a life-threatening physical endeavor. In the poorest fifth of Ghanaian society, where an average woman will have six or seven children, only 18 percent of births are attended by a skilled professional. Malnutrition among women, especially in the rural communities, is rampant and can lead to low-birth weights and deadly complications during labor such as post-partum hemorrhage. A Ghanaian woman has a one in 35 lifetime chance of dying in childbirth. In developed nations where maternal deaths are encountered very rarely, if ever, and access to family planning is taken for granted, we forget about maternal mortality; we don’t grapple with its causes or attempt to understand its effects on the children, families and communities. The image of the struggling mother represents not only the enduring struggle of being a mother, but also the hard-fought struggle even to become a mother in this setting.
 Pathfinder’s work in Ghana takes the difficult and carefully tread path of decreasing maternal mortality by addressing the deadly toll of unsafe abortion. Unsafe abortion accounts for 30 percent of maternal deaths in Ghana; most of which are entirely preventable. Although Ghana’s laws on abortion are relatively liberal, widespread stigma and lack of access to quality care lead many women to unskilled providers or even to attempt to terminate the pregnancy themselves. Young women are particularly vulnerable, comprising 60 percent of the maternal deaths from unsafe abortion. Along with the Youth Friendly Postabortion Care (YF PAC) project in Accra, Pathfinder is implementing a Comprehensive Abortion Care (CAC) project in the three Northern regions of Ghana.
The CAC project has five components, each playing an important role in achieving the goal of decreasing maternal mortality. The project aims to increase access to quality abortion care services by (1) providing a safe place where pregnant women can discuss their options, (2) giving life-saving medical care to women suffering the complications of unsafe abortion, (3) providing contraceptive methods to avert further unintended pregnancies, (4) creating community awareness of the problem of unsafe abortion and reducing stigma and (5) providing safe, elective abortion procedures when necessary. The project is comprehensive in the fact that it not only provides safe abortion and postabortion medical care, but it also addresses the root causes of unsafe abortion, including lack of knowledge, stigma, and lack of access to family planning in order to prevent future unintended pregnancies as well as unsafe abortions.
For an American, it is difficult to take abortion out of the context of our own contentious national debate. However, to accurately assess the deadly toll of unsafe abortion on women in the developing world is to forget the American context and consider the simple fact of an African woman’s life. Ninty-seven percent of unsafe abortions occur in the developing world and it is estimated that 60 percent of those are among African women under the age of 25. To ignore the consequences of unsafe abortion is to ignore the needless deaths of the women in our world’s most impoverished areas; to ignore the issue of abortion is to ignore a large portion of the world’s maternal deaths. Although controversial, comprehensive abortion care including counseling, family planning provisions, and community sensitization is an effective and proven method of reducing maternal mortality. The African mother struggles in many ways in which the American mother does not; undergoing an unsafe abortion and suffering the life-threatening consequences does not have to be part of her struggle.
*Facts and figures from WHO, Population Reference Bureau, and Ghana Health Services.
“Were you satisfied with the services you received?”
Ghana: Tuesday, July 23, 2008
 I’ve spent a lot of time during my internship within the walls of the Pathfinder’s country office in Accra. Although it is less glamorous than visiting the sites overseeing project activities, much important work (program-related and otherwise) is done behind the scenes in Ghana as well as HQ and our other country offices throughout the world. Finance, monitoring and evaluation, fundraising, communications, and various administrative functions are all important facets of Pathfinder’s work; each one is a meaningful part of the daily program work and contributes to the final impact of the organization.
One particular example of such work behind the scenes in Ghana deserves, at least I think, an out-front mention. As part of an effort to improve monitoring and evaluation of the Youth-Friendly Postabortion Care (YF PAC) project, the Ghana office is using the collection of mobile phone numbers to facilitate confidential exit interviews. In many projects exit interviews are conducted, most times immediately after the patient receives care, to measure service quality. These interviews feed a broader monitoring and evaluation effort and provide those implementing the project with patients’ views of the services rendered. However, due to the fact that PAC can be traumatic both physically and emotionally for the client, it doesn’t make sense, nor would it be appropriate, to conduct exit interviews directly following the procedure. The collection of mobile phone numbers provides an innovative solution to this problem. Moreover, through interviews conducted via mobile phones, the confidentiality of the patient is maintained, which would not be the case for home visits.
This photo shows Pathfinder staff in Accra as well as staff based in the North who happened to be in Accra for a meeting. | I have learned a lot from watching Getrude, the Assistant Program Officer and Project Coordinator for YF PAC, conduct these interviews and admire the care and concern she shows for the clients throughout her questioning. Getrude conducts the interviews in a mix of English and the local language, easing into the local language as the interview becomes more conversational and less formal. The prepared questions, dealing with pain management, interaction with the service providers and quality of family planning counseling, work to create an understanding of the services from the clients’ view; a composite of the answers informs the project in a way that site visits and record keeping alone cannot. In addition to this primary purpose, the interviews are used to check-in on the client to make sure she is well after the procedure and receiving any follow-up care that she needs. In a few of the interviews, the young women did not receive a family planning method because of various reasons, even though they were interested in receiving a method. Getrude informally counseled them on their options and encouraged them to return to the family planning clinic, giving detailed instructions as to where it was located and who would be there to help them—even going so far as to call the service provider at the family planning clinic to notify her of when the women would be coming. This kind of personalized follow-up is invaluable to the women to whom Getrude speaks and, although the impact is minor in terms of overall numbers, will make a difference in the individual lives of these young women.
The YF PAC project is a one-year privately funded initiative taking place in eight countries throughout Africa and it is truly innovative in its focus on PAC, a topic largely ignored by aid projects in the developing world, as well as its focus on the special needs of adolescent clients. Its mark on the community is not measured solely by the impact of the services rendered in that short year, but on the lessons learned and progress made throughout that year. The YF PAC program in Ghana has not been without challenges, but these challenges, if examined, can lead to successes in future programs—either for Pathfinder or another NGO—and ultimately could contribute more to the health of the community than an initial success of a more standard project. Pathfinder anticipates replicating this innovative project throughout Ghana and other African countries, so the impact of this detailed and creative monitoring (although behind the scenes!) will be felt for years to come.
Nancy Ryan's Photos from the field
Ghana: Monday, July 21, 2008
Click the image below to see recent images from Nancy's trip and learn more about Pathfinder's work with youth in Ghana.
“do women have rights?”
Ghana: Tuesday, July 1, 2008
 Every once in a while there are moments when you realize that something within someone else, or even yourself, is changing. International development work is rarely defined by big moments. Family planning and reproductive health, in particular, make their impact through the choices of individual people in the developing world. It is not so much a matter of numbers, but of attitudes and behaviors; the work is about people, not statistics. This makes everything more difficult to measure—but in some ways more meaningful as the changes in attitudes and behaviors will continue to take shape and grow long after the last program officer and NGO have migrated to the next country on their list.
Getrude and I traveled again to the Volta Region to attend two more assessment meetings of the peer education component of the Youth Friendly Services program. During the meeting, when the youth were sharing their experiences, one peer educator recounted that she had encountered a young woman who wanted family planning, but whose husband did not approve. The peer educator wanted to know what advice to give this young woman. Other peer educators immediately chimed in that they had also encountered this situation in their work throughout the community and had different ideas, advice, and challenges to report.
With much hesitation a hand went up in the front of the room. A man slightly older than the rest of the group, one of the non-traditional condom distributors (NTCD), began to speak. (Other than the peer educators, Pathfinder’s community-based outreach also relies on those who own beauty parlors, tailors and other shops to distribute condoms and sexual health information to patrons who frequent the shop; this man is part of the program in this way.) He spoke in the hypothetical, asking if it was right for a woman to seek contraception without the consent of her husband. Obviously uncomfortable with the previous conversation, he went on to say that he thought it was the husband’s right to refuse his wife’s request to use contraception.
At this point, Getrude, the fearless and remarkable Ghanaian program officer for PI, stepped in to handle his question/comment. Without a beat, she said, “Do women have rights?” She pressed on, “Do you have rights?” Walking him through various scenarios of potential disagreements between a husband and wife about issues large, Getrude was allowing him to see things through a new lens. She went on to say again, “Do women have rights?” He responded timidly and without much conviction; he said, “yes.”
 It was clear from this exchange that he was not convinced and that he needed further encouragement to fully see the point. But, he was obviously bending his mind to think in a way that he hadn’t previously. He was considering the various scenarios Getrude had enlivened in the context of “rights” for both men and women. He had the courage to ask a difficult question and the courage to listen to consider a viewpoint that wasn’t his own. I believe he took what Getrude had to say to heart, but I know that he will never view the situation or the idea of the rights of women in the same manner.
The work of the NTCDs and the peer educators is on the frontlines of their community. They don’t have all the answers, nor are they experts in adolescent sexual health, family planning or HIV/AIDS. They are valuable in their connection to their peers and those in the community who are most at risk; they are valuable because of the training they receive and their ability to transform lives through simple communications.
This moment was not just transformative for him; it reaffirmed for me the importance of challenging firmly held beliefs—something the peer educators encounter every day. It is remarkable to take part in the sharing of new ideas. And, it is refreshing to be in a place where asking an honest question is responded to with an honest answer—negating the condescension and pretense that accompanying far too many discussions in the US.
“They don’t understand”
GHANA: Wednesday, June 25, 2008
In the afternoon I visited three health facilities around Accra where, for the past year, Pathfinder has initiated Youth-Friendly Postabortion Care (YF PAC) programs. Postabortion care (PAC) is medical treatment for women suffering from the complications of unsafe abortion. The purpose of PAC is twofold: (1) to save the lives of the suffering women who enter the health facility for treatment and (2) to provide family planning counseling and services so that the women will not find themselves in this life-threatening situation again. This project was undertaken with private funds in eight countries in Africa because of the dire need for PAC services on the continent and to address the specific needs of adolescents in seeking and receiving treatment.
Since people might be unfamiliar with some of the background on this issue, here are some links to relevant info:
 Today was a challenging day for me. Although I am continually learning about and intrigued by the notion of public health and the important work that is being done in developing countries, visiting the health facilities was very difficult. I appreciated talking to the nurses and doctors, asking them questions about their work and the project. Nurses at each facility were trained to treat the women as they come in so that no patient would have to wait in pain for a doctor to care for them. The nurses at one facility, in particular, were obviously empowered by this training and their ability to directly help the women who are suffering. Nurses at another facility mentioned that before the training they had to refer the patients to another facility to receive emergency care from an available doctor; now they can perform the procedures themselves and other nurses have requested the same training. I appreciated seeing the facilities themselves, noticing the differences between a large general hospital, a clinic dedicated solely to maternal and child health, and a more rural facility—modest in its structure.
I had a difficult time coming to grips with the high-level of need and the evident suffering of the women who were there to receive services. I can’t imagine the pain and trauma that brought them to the facility. I found myself being drawn to the fact that these services are geared toward youth, who are probably scared and confused. A nurse at the first facility we visited emphasized the point that the adolescents don’t understand what is happening to their bodies when they arrive and need more time for counseling and reassurance throughout their time at the hospital. Moreover, each woman at each facility was there alone. This is probably an uncommon and insignificant fact, but this point exaggerated the feeling that these women were fighting by themselves—that this is an easily forgotten problem and undesirable project. I was also confronted by some of the challenges this ground-breaking project has faced—challenges that must plague public health projects around the globe.
 Changing Lives, Saving Lives is Pathfinder’s slogan, used on letterhead, banners and throughout various pieces of writing. I always thought the slogan was too general for PI’s mission and found it unhelpful in illuminating the diverse projects undertaken throughout the world. Visiting the health facilities today has warmed me to that slogan. The YF PAC project, although with challenges, is saving lives everyday by providing much needed quality care to women who would otherwise not receive it; the program’s emphasis on family planning as well as the budding outreach efforts will change lives and attitudes in these communities for years to come. Moreover, the innovative emphasis on the needs of adolescents, a group especially vulnerable to stigma and the least likely to seek treatment, is one that could be replicated and learned from throughout Africa and the world.
“If it’s for money, nobody would sit here”
Ghana: Wendesday, June 18, 2008
 Lucy, the nurse who leads one of Pathfinder’s Youth Friendly Services programs in the Volta region, reiterated the point many times over that the peer educators and service providers she organizes are involved in this work for the betterment of their community for the good of “our people.” I don’t doubt her; in fact, it’s obvious from the remarkable initiative of the peer educators and the dedication of the service providers that nothing else could be motivating their work. Not to mention the fact that the peer educators work entirely on a volunteer basis and the service providers receive no monetary payment over their district salaries except for modest travel and meal stipends received on meeting days. The supervisors also receive a token each quarter for meals and transportation.
Yesterday I traveled to the Volta region of Ghana (the southeastern region bordering Togo) to attend a monthly assessment meeting for PI’s Youth Friendly Services (YFS) program in both the Ho and Akatsi districts. The YFS program has two main components: (1) making reproductive health facilities more “youth-friendly” (separate procedure and counseling rooms, more convenient hours, lower fees, staff trained to talk to adolescent groups in a non-judgmental manner etc.) and (2) training peer educators to perform outreach efforts in order to disseminate sexual and reproductive health information as well as refer their peers to the health facilities, if necessary. Assessment meeting is really too formal a title for what I observed; the meetings were an opportunity for the peer educators and the service providers (mainly nurses and midwives working at the YF facilities) to come together and share both the successes and challenges of their work.
It was really amazing for me to listen to the peer educators talk about their work. Both YFS and peer educators are terms that I’ve heard thrown about during my two years at PI, but I don’t think I ever fully understood the need or the importance of these types of programs before today. Many of the peer educators in the Akatsi District talked about how STIs, HIV/AIDS, unwanted pregnancy, and drug abuse are plaguing the young people of their community. I asked many of the peer educators why they became involved in this work (they range in age from 17 to mid-twenties) and every one cited these problems in the local community and the need he/she felt to help his/her peers. When asking this question, I was expecting a more involved—or at least more varied—response, but I think the simplicity of that answer reveals both the complexity of the problem and the (small but) meaningful impact of the singular actions of these peer educators.
One young man, Patrick, led a group of four fellow peer educators, to visit two schools to talk about STI transmission, prevention, and treatment as well as the dangers of teenage pregnancy within the context of a broader discussion on family planning. He relayed the fact that the students at the schools were quite engaged and very participatory during the session and the schools’ administration, because of the positive response by the students as well as the peer educators’ ability to lead the session in the local language, requested a second visit by the group. Beyond this success at the school, Patrick went to talk to the local assemblyman and arranged for the airing of the peer educators’ presentation on a local radio station that is broadcast in public areas throughout the town; the presentation is expected to air in three towns in the coming weeks. The initiative needed to organize and perform all those tasks—while receiving no pay…while talking about sexual health with perfect strangers…while traveling long distances—is truly extraordinary…at least, that’s more than I do in an average day.
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